護理師照護輸血病人時,應採取哪些措施以預防輸血反應?(選所有適合的)
A nurse is providing care to a client receiving a blood transfusion. Which actions should the nurse take to prevent a transfusion reaction? (Select all that apply.)
- AVerify the blood product with another licensed nurse✓ 正解與另一位持照護理人員核對血液製品
- BCheck the expiration date on the blood bag✓ 正解檢查血袋上的有效期限
- CWarm the blood product in a microwave to room temperature將血液製品於微波爐中加熱至室溫
- DInfuse the blood using a dedicated Y-tubing set with a filter✓ 正解使用帶有濾網的專用 Y 型管路輸注血液
- EMonitor vital signs every 15 minutes during the first hour✓ 正解於第一小時內每 15 分鐘監測生命徵象
輸血(Blood Transfusion)是高風險程序,必須嚴格遵守「雙人核對(Double-check)」程序,確認血液製品與病人資料完全吻合。輸血過程中,前 15 分鐘必須緩慢滴注,因為這是最容易發生溶血反應(Hemolytic reaction)的時間段。護理師需密切監測生命徵象,任何異常(如發燒、寒顫、腰痛)都必須立即停止輸血。
Blood transfusion is a high-risk procedure that requires strict double-check by two licensed nurses to verify that the blood product and the client's information match completely. During transfusion, the infusion must run slowly for the first 15 minutes, because this is the period during which hemolytic reactions are most likely to occur. The nurse must closely monitor vital signs, and any abnormality (such as fever, chills, or back pain) must prompt immediate cessation of the transfusion.