— 照護管理 · MEDIUM · MCQ —
護理師負責執行輸血作業，下列哪項措施能確保病人安全？
A nurse is caring for a client who requires a blood transfusion. Which action should the nurse take to ensure client safety?
- AAdminister the transfusion over 6 hours to prevent fluid overload於 6 小時內輸注以預防液體過載
- BVerify the blood product with another nurse at the bedside✓ 正解在床邊由另一位護理師核對血液製品
- CWarm the blood product in a microwave to prevent hypothermia以微波加熱血液製品以預防低體溫
- DUse an infusion pump to deliver blood at a rapid rate immediately使用輸注幫浦立即快速輸注血液
— Explanation · 中文詳解 —
輸血作業中，雙人核對（Double-check）是最關鍵的安全防護機制，需確認血液類型、病人姓名、病歷號等資訊完全一致。C 選項加熱血液會破壞紅血球；A 選項過慢會增加細菌繁殖風險；D 選項除了緊急情況，輸血速度過快易導致循環負荷過重或肺水腫。
In blood transfusion procedures, a two-nurse double-check is the most critical safety mechanism, confirming that blood type, client name, and medical record number all match exactly. Option C (heating the blood) destroys red blood cells; option A (infusing too slowly) increases the risk of bacterial proliferation; option D except in emergencies, infusing too rapidly can cause circulatory overload or pulmonary edema.
✦ 台美臨床差異
台美均嚴格執行雙人核對；美國多使用電子掃描系統進行床邊核對，台灣則多維持人工核對簽章紀錄。