護理師監督一位新進護理師準備輸血，新進護理師採取哪項行為需立即介入？
A nurse is supervising a newly licensed nurse who is preparing to hang a blood transfusion. Which action by the new nurse indicates a need for intervention?
- AChecking the blood label against the client’s ID band with another nurse與另一位護理師核對血液標籤與病患識別手環
- BObtaining baseline vital signs before beginning the transfusion在開始輸血前取得基線生命徵象
- CStarting the transfusion with D5W intravenous solution✓ 正解使用 D5W 靜脈注射溶液開始輸血
- DUsing a filtered blood administration set for the transfusion使用帶有過濾器的血液輸注套組進行輸血
輸血安全是 NCLEX 管理照護的核心考點。血液製品必須僅與 0.9% 生理食鹽水（Normal Saline）兼容。D5W（5% Dextrose in Water）是一種低張溶液（hypotonic solution），若與血液混合，會導致紅血球細胞內滲透壓改變，引發紅血球腫脹甚至溶血（hemolysis），進而造成病人發生致命的輸血反應。作為監督者，護理師需確保輸血流程嚴格遵守標準作業程序，任何可能危害病人安全的行為都必須立即介入停止。
Blood products must never be infused with D5W because the hypotonic solution causes red blood cells to swell and lyse, leading to potentially fatal transfusion reactions. Only 0.9% sodium chloride (normal saline) is compatible with blood transfusions. Initiating a transfusion with D5W indicates a critical error requiring immediate intervention by the supervising nurse.
台美臨床對於輸血管路配置幾乎一致。美國醫院通常嚴格要求輸血管路僅能銜接生理食鹽水，並有專門的 Y 型輸血套組（Y-type blood tubing），這點與台灣臨床實務相同。