— 降低風險 · MEDIUM · SATA —
護理師正在為病人進行輸血。下列哪些發現暗示可能發生輸血反應？（選所有適合的）
A nurse is caring for a client who is receiving a blood transfusion. Which of the following findings indicate a potential transfusion reaction? (Select all that apply.)
- ASudden onset of chills and fever✓ 正解突然出現寒顫和發燒
- BReporting of flank pain✓ 正解主訴後腰疼痛
- CDevelopment of hives and itching✓ 正解出現蕁麻疹和搔癢
- DRespiratory rate increase of 2 breaths/min呼吸頻率增加 2 次/分
- EHypotension✓ 正解低血壓
— Explanation · 中文詳解 —
輸血反應表現多樣：寒顫與發燒暗示發熱性反應；腰痛暗示溶血反應（溶血會導致血紅素塞住腎小管）；蕁麻疹與搔癢為過敏反應；低血壓則是嚴重過敏或急性溶血反應的表現。呼吸速率微幅上升屬正常波動，不一定代表反應。
Chills, fever, flank pain, hives, and hypotension are cardinal signs of transfusion reactions, including febrile, hemolytic, and allergic responses. A minor increase in respiratory rate alone is often due to anxiety and is not a specific indicator of a reaction.
✦ 台美臨床差異
美國醫院輸血需兩人雙簽核對；台灣亦然，但台灣護理師通常會全程監控前 15 分鐘的生命徵象更為嚴謹。