— 降低風險 · MEDIUM · SATA —
護理師照護輸血病人，哪些症狀顯示出現輸血反應？（選所有適合的）
A nurse is caring for a client who is receiving blood transfusion. Which manifestations indicate a transfusion reaction? (Select all that apply.)
- ABack pain✓ 正解背痛
- BChills and fever✓ 正解畏寒和發燒
- CHypertension高血壓
- DItching and urticaria✓ 正解搔癢和蕁麻疹
- EShortness of breath✓ 正解呼吸困難
— Explanation · 中文詳解 —
輸血反應表現多樣。背痛常見於急性溶血反應，因腎血管阻塞所致；寒顫發燒為發熱性非溶血反應；皮膚搔癢及蕁麻疹代表過敏反應；呼吸困難則可能為過敏性休克或輸血相關急性肺損傷（TRALI）。輸血反應常伴隨低血壓而非高血壓。
Back pain is a classic sign of acute hemolytic reaction due to renal vascular obstruction, while chills and fever indicate febrile non-hemolytic reactions. Itching and urticaria suggest a hypersensitivity reaction to plasma proteins, and shortness of breath may indicate anaphylaxis or transfusion-related acute lung injury (TRALI). Transfusion reactions are typically associated with hypotension rather than hypertension.
✦ 台美臨床差異
美國輸血前需雙人確認且流程極嚴格；台灣臨床對輸血反應的警覺性高，但電子化雙人核對普及度各院不同。