護理師為病人執行輸血時，下列哪項發現需要立即採取介入措施？
Which assessment finding in a client receiving a blood transfusion requires immediate intervention by the nurse?
- AMild itching without rash無皮疹的輕微搔癢
- BBlood pressure increase of 5 mmHg血壓上升 5 mmHg
- CSlight decrease in heart rate心跳輕微下降
- DBack pain and flank pain✓ 正解背痛和側腹痛
輸血反應中，腰背疼痛（back/flank pain）是急性溶血性輸血反應（Acute Hemolytic Transfusion Reaction）的關鍵特徵。這起因於輸入的紅血球與受血者抗體發生不相容，導致紅血球大量破裂，釋放血紅素沉積於腎小管，可能引發急性腎衰竭。護理師必須執行「立即停止輸血」的最高優先原則，更換管路並以生理食鹽水維持靜脈通暢，以保護腎臟功能並預防休克。
Back or flank pain during a blood transfusion is a hallmark sign of an acute hemolytic reaction, requiring immediate intervention. This reaction occurs when incompatible blood causes red blood cell destruction, potentially leading to renal failure and shock. The nurse must stop the transfusion immediately, keep the IV line open with saline, and notify the provider.
在美國臨床，一旦懷疑溶血反應，Protocol 通常要求立即停止輸血並以生理食鹽水 (Normal Saline) 更換管路以維持靜脈通路 (KVO)，隨後立即通知醫師與血庫 (Blood Bank) 進行後續採檢。