— 照護管理 · MEDIUM · SATA —
護理師正在照護一位需要輸血的病人。下列哪些行動是確保輸血安全的必要程序？（選所有適合的）
A nurse is caring for a client who requires a blood transfusion. Which actions are necessary to ensure safety? (Select all that apply.)
- AObtain two licensed nurses to verify the blood product✓ 正解由兩位持照護理師核對血液製品
- BUse normal saline as the flushing solution for the blood line✓ 正解使用生理食鹽水作為輸血管路的沖洗液
- CStart the transfusion immediately after obtaining it from the blood bank✓ 正解從血庫取得血液後立即開始輸血
- DMonitor the client's vital signs every 15 minutes for the first hour✓ 正解在最初一小時內每15分鐘監測個案的生命徵象
- EVerify the patient's identity using two unique identifiers✓ 正解使用兩種獨特的識別碼驗證病人身份
— Explanation · 中文詳解 —
輸血是高風險醫療行為，必須嚴格遵循安全規範。核心概念包括雙重核對（Two-nurse verification）、正確的身份識別（Two identifiers）、輸血前監測以及使用生理食鹽水沖管以避免溶血。臨床思路應將輸血視為一個完整的安全閉環，從血庫領血、床邊核對到輸血過程中的監測，每一個環節都不可缺失。
Blood transfusion safety requires verifying the patient's identity with two unique identifiers and having two licensed nurses cross-check the blood product. Only normal saline should be used to flush the line to prevent hemolysis, and the transfusion must begin within 30 minutes of retrieval to minimize bacterial growth. Vital signs should be monitored frequently, especially during the first 15 to 30 minutes, to detect early signs of a reaction.