— 降低風險 · MEDIUM · SATA —
下列哪些評估發現會警示護理師病人可能出現輸血併發症？（選所有適合的）
Which of the following assessments would alert the nurse to potential complications in a client receiving a blood transfusion? (Select all that apply.)
- ASudden onset of chills and fever✓ 正解畏寒與發燒突然發作
- BLow back pain✓ 正解下背痛
- CIncreased urine output尿量增加
- DDevelopment of hives or rash✓ 正解出現蕁麻疹或皮疹
- EShortness of breath and wheezing✓ 正解呼吸困難與喘鳴
— Explanation · 中文詳解 —
輸血反應包含發熱性、溶血性與過敏性反應。發熱發冷（A）、腰痛（B，溶血警訊）、皮疹（D，過敏）、呼吸困難喘鳴（E，過敏或液體負荷）均為異常。尿量增加（C）通常非輸血直接導致之併發症，反之溶血反應可能導致血紅素尿及腎衰竭導致尿量減少。
Signs of transfusion reactions include fever and chills (febrile reaction), low back pain (hemolytic reaction), hives (allergic reaction), and dyspnea with wheezing (anaphylaxis or circulatory overload). Increased urine output is not a typical sign of these acute complications.
✦ 台美臨床差異
美台皆嚴格執行輸血核對，但美國護理師對輸血反應監測的 SOP 通常包含更詳細的即時回報系統。