— 照護管理 · MEDIUM · SATA —
護理師準備輸血時應執行哪些步驟？（選所有適合的）
Which actions should a nurse take when preparing to administer blood products? (Select all that apply.)
- AVerify the blood product with another licensed nurse✓ 正解與另一位執業護理師核對血液製品
- BCheck the client's identification against the blood label✓ 正解將病人身分與血袋標籤進行核對
- CObtain baseline vital signs before starting the infusion✓ 正解在開始輸注前取得基礎生命徵象
- DFlush the IV line with 0.9% Normal Saline only✓ 正解僅以 0.9% 生理食鹽水沖洗靜脈通路
- EEnsure the client has a patent large-bore IV catheter✓ 正解確保病人擁有暢通的大管徑靜脈導管
— Explanation · 中文詳解 —
輸血是高風險護理行為，必須嚴格執行雙人核對。包括：核對病人識別與血品資料、輸血前測量基準生命徵象、使用生理食鹽水作為輸注液（避免溶血）、確保靜脈管路暢通（通常建議 18-20 G 針頭）。上述皆為臨床安全守則。
Administering blood products requires strict safety protocols, including dual-nurse verification of the client and blood product to prevent transfusion errors. Nurses must check client identification, obtain baseline vital signs, ensure a patent large-bore IV catheter, and flush the line only with 0.9% Normal Saline to avoid hemolysis. These steps are critical for preventing adverse reactions and ensuring safe delivery.
✦ 台美臨床差異
台美皆嚴格執行三讀五對。台灣輸血多需兩名護理師同時於床邊核對，美國亦同。