— 降低風險 · HARD · SATA —
護理師監測輸血病人，哪些跡象顯示可能發生溶血性輸血反應？（選所有適合的）
A nurse is monitoring a client who is receiving a blood transfusion. Which signs indicate a possible hemolytic transfusion reaction? (Select all that apply.)
- ALow back pain✓ 正解下背痛
- BChills and fever✓ 正解畏寒與發燒
- CHypotension✓ 正解低血壓
- DFacial flushing臉部潮紅
- EWheezing哮鳴音
— Explanation · 中文詳解 —
溶血性輸血反應通常起因於 ABO 血型不相容。病人會出現典型的腰痛（紅血球裂解導致腎小管堵塞）、畏寒、發熱及低血壓。臉部潮紅與喘鳴（Wheezing）多見於過敏性反應。護理師應在懷疑時立即停止輸血並以生理食鹽水維持靜脈路徑。
Hemolytic transfusion reactions, often caused by ABO incompatibility, typically present with low back pain due to renal tubule obstruction by red cell debris, along with chills, fever, and hypotension from vasoactive substance release. In contrast, facial flushing and wheezing are more indicative of hypersensitivity or allergic reactions.
✦ 台美臨床差異
美國輸血紀錄監控極為嚴格，護理師需在輸血後 15 分鐘留守床邊；台灣同樣遵循嚴謹的輸血 SOP。