— 降低風險 · MEDIUM · SATA —
護理師監測輸血中的病人。下列哪些症狀提示發生溶血性輸血反應？（選所有適合的）
A nurse is monitoring a client receiving a blood transfusion. Which symptoms should lead the nurse to suspect a hemolytic reaction? (Select all that apply.)
- ALow back pain✓ 正解背痛
- BFever and chills✓ 正解發燒與寒顫
- CHypotension✓ 正解低血壓
- DItchy skin rash搔癢性皮疹
- EDark-colored urine✓ 正解深色尿液
— Explanation · 中文詳解 —
溶血性輸血反應是由於 ABO 血型不符導致紅血球大量破壞。典型表現為背部疼痛（腎臟受損）、發燒發冷（全身性免疫發炎）、低血壓（血管擴張）以及血紅素尿（深色尿）。搔癢皮疹通常與過敏反應相關，非溶血性反應的主徵。
A hemolytic reaction due to ABO incompatibility typically presents with low back pain, fever, chills, hypotension, and dark-colored urine from hemoglobinuria. These symptoms result from acute red blood cell destruction and systemic immune response, distinguishing them from allergic reactions characterized by itching or rash.
✦ 台美臨床差異
美台皆採嚴格雙人核對制度，台灣常見於輸血前由兩位護理師在床邊核對，美國則部分醫院採用條碼識別系統。