— 照護管理 · MEDIUM · MCQ —
護理師監督一名新進護理師執行輸血作業，下列哪項動作需要立即介入？
A nurse is supervising a newly licensed nurse who is preparing to hang a blood transfusion. Which action by the new nurse requires immediate intervention?
- AVerifying the patient identification with another nurse at the bedside在床邊與另一位護理師核對病人身分
- BChecking the blood type and cross-match report against the patient's ID band將血型與交叉配血報告與病人識別手環進行比對
- CPriming the blood tubing with Lactated Ringer's solution✓ 正解使用林格氏乳酸鹽溶液沖洗輸血管路
- DMonitoring the client's vital signs every 15 minutes during the start of the transfusion在輸血開始期間每 15 分鐘監測病人生命徵象
— Explanation · 中文詳解 —
輸血時僅能使用 0.9% 生理食鹽水（Normal Saline）進行沖管與維持管路通暢。使用乳酸林格氏液（Lactated Ringer's）含有鈣離子，可能會造成輸血袋中的血液發生凝血反應，這是輸血作業中嚴重的技術錯誤，必須立即阻止，否則會危及病人的血液循環安全。
During blood transfusion, only 0.9% normal saline may be used to flush the line and maintain patency. Lactated Ringer's solution contains calcium ions, which can cause the blood in the transfusion bag to clot. This is a serious technical error during blood administration and must be stopped immediately; otherwise it can jeopardize the safety of the client's circulating blood.
✦ 台美臨床差異
美台臨床皆嚴格規定輸血僅能使用生理食鹽水，此為國際共識。