— 生理適應 · EASY · MCQ —
護理師評估一位正在接受輸血的病人，哪項發現顯示發生溶血反應？
A nurse is evaluating a client receiving a blood transfusion. Which finding indicates a hemolytic reaction?
- AHypertension高血壓
- BWheezing哮鳴音
- CFlank pain✓ 正解側腹疼痛
- DUrticaria蕁麻疹
— Explanation · 中文詳解 —
急性溶血性輸血反應（Acute hemolytic transfusion reaction）是由於ABO血型不相容導致的嚴重免疫反應。紅血球破裂釋放出的血紅素會造成腰痛（Flank pain）、發燒、寒顫、血紅素尿（Hemoglobinuria）及低血壓。這是致命性的反應，護理師若發現應立即停止輸血，並以生理食鹽水維持靜脈通路，保護腎臟功能。
Flank pain is a classic sign of an acute hemolytic transfusion reaction, which occurs due to ABO incompatibility and results in red blood cell destruction. This life-threatening reaction also presents with fever, chills, hemoglobinuria, and hypotension, requiring immediate cessation of the transfusion and renal protection measures.