— 降低風險 · MEDIUM · MCQ —
護理師監測一位正在輸血的病人。下列哪項發現暗示病人可能發生溶血性輸血反應？
A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates a potential hemolytic reaction?
- ALow back pain and dark urine✓ 正解下背痛與深色尿液
- BDecreased blood pressure and fever血壓下降與發燒
- CWheezing and hives喘鳴與蕁麻疹
- DSlow bounding pulse緩慢且強而有力的脈搏
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）是一種嚴重的輸血併發症，通常由 ABO 血型不相容引起。當受體體內的抗體攻擊輸入的供體紅血球，會造成紅血球大量破壞（溶血），釋放出游離血紅素，進而導致腎小管阻塞。臨床表現包括腰背部劇痛（反映腎臟受損）、發燒、寒顫、低血壓、心跳過快，以及因血紅素尿導致的深色尿液。
Acute hemolytic transfusion reactions, often caused by ABO incompatibility, result in the destruction of red blood cells and release of free hemoglobin, leading to hemoglobinuria and flank or low back pain. These symptoms indicate renal compromise and require immediate cessation of the transfusion and emergency intervention.