護理師照護一位接受輸血的病人。下列哪些徵象顯示可能出現輸血反應？（選所有適合的）
A nurse is caring for a client receiving a blood transfusion. Which of the following signs indicate a potential transfusion reaction? (Select all that apply.)
- AChills and fever✓ 正解寒顫與發燒
- BLow back pain✓ 正解下背痛
- CSudden itching or hives✓ 正解突發性搔癢或蕁麻疹
- DDecreased blood pressure✓ 正解血壓下降
- EHypoactive bowel sounds腸鳴音減弱
輸血反應（Transfusion reaction）的早期徵象多在輸血開始後 15 分鐘內出現，必須立即停止輸血、改打生理食鹽水保持靜脈通路、並通知醫師。 選項 A 寒顫與發燒：最常見徵象，可能為發燒性非溶血反應或細菌污染。 選項 B 下背痛：急性溶血性反應的典型徵象，反映腎臟受損。 選項 C 突發搔癢/蕁麻疹：過敏反應（mild allergic reaction）的指標。 選項 D 血壓下降：嚴重溶血或過敏性休克的徵象。 選項 E 腸鳴音減少：與輸血反應無關，多為胃腸動力或腹部問題。 NCLEX 重點：發現任一徵象都應立即停止輸血、保留血袋、評估生命徵象並通報。
Transfusion reactions typically appear within the first 15 minutes of infusion and require immediate action: stop the transfusion, maintain IV access with normal saline, and notify the physician. A: Chills and fever — the most common reaction, indicating febrile non-hemolytic or bacterial contamination. B: Low back pain — classic sign of acute hemolytic reaction reflecting renal involvement. C: Sudden itching or hives — indicates a mild allergic reaction. D: Decreased blood pressure — indicates severe hemolysis or anaphylaxis. E: Hypoactive bowel sounds is unrelated to transfusion reactions and reflects GI motility issues. NCLEX priority: any of these signs warrants stopping the transfusion immediately, preserving the blood bag, assessing vitals, and notifying the provider.