— 藥理與非經腸給藥 · MEDIUM · SATA —
護理師執行輸血作業，下列哪些行動能確保安全性？（選所有適合的）
A nurse is administering a blood transfusion to a client. Which actions should the nurse take to ensure safety? (Select all that apply.)
- AVerify the blood product with another licensed nurse at the bedside✓ 正解在床邊由另一位執業護理師共同核對血液製品
- BUse a dedicated IV line with a Y-tubing set and normal saline✓ 正解使用專用靜脈通路，配備 Y 型管組和生理食鹽水
- CWarm the blood in a microwave to prevent hypothermia使用微波爐加熱血液以防止低溫
- DMonitor the client's vital signs every 15 minutes during the first hour✓ 正解在輸血第一小時內每 15 分鐘監測病人生命徵象
- EStart the transfusion slowly for the first 15 minutes✓ 正解在最初 15 分鐘內緩慢開始輸血
— Explanation · 中文詳解 —
輸血是高風險護理操作。必須兩人核對病人資料與血袋資訊，使用專用管路與生理食鹽水，並在初始 15 分鐘慢速滴注，密切監測反應。嚴禁使用微波爐加熱血液，這會破壞紅血球並導致嚴重溶血，必須使用專業的血液加溫器。
Blood transfusion is a high-risk nursing procedure. Two nurses must verify the client's identity and blood product information, dedicated tubing with normal saline must be used, and the infusion should run slowly for the first 15 minutes with close monitoring for reactions. Heating blood in a microwave is strictly prohibited because it destroys red blood cells and causes severe hemolysis; a dedicated blood warmer must be used.
✦ 台美臨床差異
美國採兩人核對簽名制，台灣亦同，皆重視輸血前 15 分鐘的監測紀錄。