# 臨床情境 紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。 請標示支持伴隨溶血與休克風險之急性嚴重輸血反應的發現。不要選取設備完整或穩定的發現。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522656&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

臨床情境
紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。

請標示支持伴隨溶血與休克風險之急性嚴重輸血反應的發現。不要選取設備完整或穩定的發現。

輸血記錄\個案在輸血前感到舒適。紅血球開始輸注十二分鐘後，個案報告突發性寒顫、嚴重下背痛和胸悶。發現包括血壓 82/48 mm Hg、心率 128/min和導尿管中出現新的深紅色尿液。靜脈注射部位乾燥無腫脹，輸注單位正透過過濾器輸注，雙側肺音仍清晰。

## 解析

寒顫、嚴重下背痛、胸悶、低血壓、心搏過速和深色尿液是急性輸血反應的線索。必須停止輸血，同時評估個案並調查反應。

## 深入解析

快速解答
辨識輸血期間的全身性症狀、疼痛、血流動力學變化和血紅素尿。

為什麼這是正確的
急性溶血可能在接觸不相容紅血球的幾分鐘內開始。發燒或寒顫也需要調查細菌污染，而不是假設反應是良性的。

簡單類比或心像
將每次輸注視為受控的臨床系統：驗證產品和通路、辨識變化的線索、停止可預防的暴露、穩定個案並確認反應。

記憶點
產品、通路、相容性、輸注線索、保護措施和重新評估。

NCLEX 決策規則
選擇能預防最直接輸注相關傷害的措施，同時保留血管通路和醫囑診斷證據。

為什麼其他選項是錯誤的
重新啟動可疑產品、繞過安全裝置、強行疏通阻塞的管路或延遲重新評估的選項，可能將可逆的警告轉變為嚴重的傷害。References
1CDC NHSN Hemovigilance Module Surveillance Protocol, January 2026Definitions and clinical patterns for acute hemolytic reaction, TACO, TRALI, and transfusion-transmitted infection
2CDC Clinical Guidance for Bacterial Contamination and Blood SafetyStop a suspected contaminated transfusion, preserve the unit, culture the patient, and investigate the residual component
3FDA-recognized Circular of Information for Blood and Blood ComponentsTransfusion reaction recognition, immediate discontinuation, product investigation, and supportive care

## 臨床情境

臨床情境
紅血球輸注開始 12 分鐘後，病人出現突發寒顫、嚴重下背痛、胸悶、低血壓、心搏過速與深紅色尿液，需要立即處理可能伴隨溶血與休克的嚴重輸血反應。

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