護理師準備為病人進行輸血。下列哪些步驟能確保病人安全？（選所有適合的）
A nurse is preparing to administer a blood transfusion to a client. Which actions should the nurse take to ensure client safety? (Select all that apply.)
- AVerify the blood product with another licensed nurse at the bedside✓ 正解在床邊與另一位執業護理師共同核對血液製品
- BObtain baseline vital signs before initiating the infusion✓ 正解在開始輸注前取得基準生命徵象
- CUse a 22-gauge or smaller needle to prevent hemolysis使用 22 號或更小的針頭以防止溶血
- DEnsure the client has a patent peripheral IV access of at least 20-gauge✓ 正解確保病人擁有至少 20 號的周邊靜脈通路
- ERemain with the client for the first 15 minutes of the infusion✓ 正解在輸注開始的前 15 分鐘內陪伴在病人身邊
輸血是高風險護理操作，需嚴格執行雙人核對流程。為確保快速輸注及預防紅血球溶血，應使用 18-20 號針頭。輸血前必須取得基準生命徵象以利對比，並在最初 15 分鐘密切監測病人是否有輸血反應徵象（如畏寒、呼吸困難、過敏等）。C 選項錯誤，太小的針頭（如 22 號）會導致血球機械性破壞，增加溶血風險。
Safe blood administration requires two-licensed-person verification of product, patient identifiers, and orders at the bedside (A); baseline vital signs before initiation (B); a large-bore IV (18-20 gauge) to ensure flow and prevent mechanical hemolysis (D, not 22 gauge); and remaining with the client for the first 15 minutes during which most acute hemolytic reactions occur (E). A 22-gauge or smaller needle (C) is incorrect because small bore causes shear stress and red cell destruction.
台灣輸血需醫師簽署同意書及嚴格的雙人血袋查對；美國亦同，但護理師在確認血型匹配與輸血程序上的授權程度更高。