護理師為病人輸血時，應採取哪些措施？（選所有適合的）
Which of the following actions should the nurse perform when administering blood products to a client? (Select all that apply.)
- AVerify the blood product with another licensed nurse✓ 正解與另一位具執照護理師共同核對血液製品
- BUse normal saline as the only compatible IV solution✓ 正解僅使用生理食鹽水作為相容的靜脈輸液
- CMonitor the client for fever or chills for the first 15 minutes✓ 正解輸血最初 15 分鐘內監測病人是否有發燒或畏寒
- DWarm the blood in a microwave to prevent hypothermia使用微波爐加熱血液以防止低體溫
- EEnsure the IV catheter is at least 20-gauge✓ 正解確保靜脈導管至少為 20 號
輸血（blood transfusion）是高風險護理程序，必須嚴格遵守安全規範以防致命的溶血反應、感染與敗血症。 選項 A 正確：兩名合格護理師雙人核對血品（血型、ABO/Rh、病人 ID、血品編號、有效期）是預防錯誤輸血最重要的關卡。 選項 B 正確：0.9% 生理食鹽水（normal saline）是唯一與血液相容的靜脈輸液。葡萄糖溶液會造成溶血；乳酸林格氏液含鈣，會與儲血用的檸檬酸抗凝劑結合導致凝血。 選項 C 正確：輸血開始的前 15 分鐘是急性溶血或過敏反應高峰期，必須密切監測生命徵象與症狀（寒顫、發熱、下背痛）。 選項 E 正確：使用 20G 或更粗（更小號數）的針頭，避免血球在通過細管路時受壓力破裂（機械性溶血）。 選項 D 錯誤：絕對禁止用微波加熱血液。微波會造成蛋白質變性、細胞溶解與不均勻加熱，可能導致致命的高血鉀與溶血。需加熱時必須使用專用血液加熱器（blood warmer）。
Blood transfusion is a high-risk procedure requiring strict safety protocols to prevent fatal hemolytic reactions, infection, and sepsis. A is correct: Two licensed nurses must verify blood type, ABO/Rh, patient ID, unit number, and expiration—the most critical safeguard against ABO-incompatible transfusion. B is correct: 0.9% normal saline is the only IV solution compatible with blood. Dextrose causes hemolysis; lactated Ringer's contains calcium that binds to citrate anticoagulant and causes clotting. C is correct: The first 15 minutes are when acute hemolytic and anaphylactic reactions peak; close monitoring of vitals and symptoms (chills, fever, back pain) is mandatory. E is correct: A 20-gauge or larger (smaller number) catheter prevents mechanical hemolysis from pressure on red cells through narrow tubing. D is incorrect: Microwaving blood is absolutely contraindicated—it causes protein denaturation, cell lysis, uneven heating, and life-threatening hyperkalemia and hemolysis. Only dedicated blood warmers may be used.