— 藥理與非經腸給藥 · MEDIUM · SATA —
執行輸血時，下列哪些護理措施是正確的？（選所有適合的）
Which of the following nursing actions are appropriate when administering a blood transfusion? (Select all that apply.)
- AVerify the blood product with another nurse at the bedside✓ 正解在床邊由另一位護理師共同核對血液製品
- BUse a 24-gauge IV catheter for optimal flow使用24號靜脈留置針以獲得最佳血流
- CInfuse blood using normal saline only✓ 正解僅使用生理食鹽水輸注血液
- DMonitor for transfusion reactions during the first 15 minutes✓ 正解輸血最初15分鐘內監測是否有輸血反應
- ECheck the client's vital signs before starting✓ 正解開始輸血前測量病人的生命徵象
— Explanation · 中文詳解 —
輸血屬高風險護理流程。核對需雙人簽章以確保病人與血袋正確。僅能搭配生理食鹽水，不得添加其他藥物。前 15 分鐘為溶血反應高峰，須嚴密監測。管徑過小（24G）會導致紅血球受損破裂，通常建議 18-20G。
Administering blood transfusions requires two-nurse verification at the bedside and using only normal saline to prevent hemolysis or incompatibility. Nurses must establish baseline vital signs and closely monitor the client during the first 15 minutes, as this is the highest risk period for acute transfusion reactions.
✦ 台美臨床差異
兩地皆重視輸血安全，美國醫院多使用條碼掃描系統進行雙重核對，台灣醫院多採紙本核對單雙人簽名確認。