— 降低風險 · HARD · MCQ —
一位病人有輸血醫囑，輸血前護理師的首要行動為何？
A client has an order for a blood transfusion. What is the nurse's priority action before starting the infusion?
- AObtain baseline vital signs取得基礎生命徵象
- BExplain the signs of a transfusion reaction to the client向病人說明輸血反應的徵象
- CPrime the tubing with 0.9% Normal Saline以 0.9% 生理食鹽水沖洗管路
- DVerify the blood product with another nurse at the bedside✓ 正解在床邊與另一位護理師共同查對血液製品
— Explanation · 中文詳解 —
輸血中最致命的錯誤是給錯血型。雖然上述選項都是輸血流程中的重要步驟，但「雙人核對」（驗證血袋、病人識別、血型）是防範溶血性輸血反應的最後一道防線，屬於病人安全之關鍵步驟，必須在輸血前由兩位合格護理人員共同執行。
Verifying the blood product with another nurse at the bedside is the priority action to prevent fatal ABO incompatibility errors. While obtaining vital signs, educating the client, and priming tubing are essential steps, double-checking ensures patient safety against transfusion reactions caused by human error.
✦ 台美臨床差異
台灣目前醫院多導入輸血條碼自動化核對系統，但法律規定仍需雙人護理師確認，這與美國強調的雙人簽署流程一致。