— 生理適應 · MEDIUM · SATA —
病人輸血時，護理師應監測哪些徵象？（選所有適合的）
Which signs or symptoms should the nurse monitor for in a patient receiving blood transfusion? (Select all that apply.)
- AFlank pain✓ 正解腰部疼痛
- BChills and fever✓ 正解畏寒與發燒
- CItching or urticaria✓ 正解搔癢或蕁麻疹
- DBradycardia心動過緩
- EDyspnea✓ 正解呼吸困難
— Explanation · 中文詳解 —
輸血反應涵蓋溶血反應、過敏反應及輸血相關循環負荷。腰痛（Flank pain）是溶血反應的特徵，畏寒發燒代表發熱反應，搔癢或蕁麻疹為過敏反應，呼吸困難則可能提示過敏或肺水腫（TACO）。心跳過慢通常不是輸血反應的典型指標。
Nurses should monitor for signs of transfusion reactions, including flank pain (indicating hemolytic reaction), chills and fever (febrile reaction), itching or urticaria (allergic reaction), and dyspnea (potential anaphylaxis or TACO). Bradycardia is not a typical sign of transfusion reactions; tachycardia is more commonly observed.
✦ 台美臨床差異
台美均嚴格執行輸血監測，美國護理師在輸血後 15 分鐘內必須在床邊監測，台灣臨床常要求第一袋血須由兩位護理師核對，流程極其嚴謹。