下列哪種輸血時的發現，需要護理師立即介入？（選所有適合的）
Which of the following findings in a client receiving a blood transfusion requires immediate intervention by the nurse? (Select all that apply.)
- ABack pain and flank tenderness✓ 正解背痛與側腹壓痛
- BTemperature increase from 37.0°C to 37.5°C體溫從 37.0°C 上升至 37.5°C
- CDevelopment of urticaria and flushing✓ 正解出現蕁麻疹與皮膚潮紅
- DComplaints of dyspnea and wheezing✓ 正解主訴呼吸困難與喘鳴
- EHeart rate increase from 72 to 110 beats per minute✓ 正解心率從 72 次/分增加至 110 次/分
輸血反應（Transfusion Reaction）是臨床緊急狀況，護理師需立即停止輸血並維持靜脈管路暢通（使用生理食鹽水）。背痛是急性溶血反應的典型特徵；蕁麻疹與潮紅代表過敏反應；呼吸困難與喘鳴暗示過敏或體液過載；心跳過速則常伴隨嚴重溶血或過敏反應。體溫微幅上升（<1°C）通常無須緊急停輸，但需密切監測。
Immediate intervention is required for back pain, urticaria, dyspnea, and tachycardia, as these are signs of acute hemolytic, allergic, or circulatory overload reactions. Back pain is a classic symptom of hemolysis, while respiratory distress and hives suggest severe allergic responses. A slight temperature increase of less than 1°C is typically monitored rather than requiring immediate cessation, whereas significant vital sign changes indicate systemic compromise.
美國醫院臨床 SOP 極為嚴格，發生任何輸血反應時，護理師除了停止輸血並更換管路，必須立即通知輸血中心（Blood Bank），並將剩餘血液與原始血袋送回檢驗，這是確保病人安全的重要流程。