護理師準備給予病人輸血,哪項措施對預防輸血反應至關重要?
A nurse is preparing to administer a blood transfusion. Which action is crucial for preventing a transfusion reaction?
- AInfuse the blood product through a central venous catheter.通過中心靜脈導管輸注血液製品
- BAdminister the transfusion rapidly to minimize exposure.快速輸注以減少暴露時間
- CObtain vital signs only at the beginning and end of the transfusion.僅在輸血開始和結束時測量生命徵象
- DEnsure proper identification of the client and the blood product before starting.✓ 正解確保在開始前正確識別病人和血液製品
輸血反應(transfusion reaction)可能危及生命,因此輸血前的準備與執行過程中的安全措施至關重要。輸血安全的核心在於確保輸注的血液與病人相符,避免免疫系統產生排斥。正確答案 D 指出「在開始輸血前,確實核對病人的身份和血品資訊」,這是預防輸血反應(尤其是 ABO 不合的溶血反應)最關鍵的第一步。這通常需要兩位醫護人員進行雙重核對(double check),包括病人姓名、病歷號碼、血型、 Rh 因子以及血袋上的相關資訊。選項 B(快速輸血)可能增加心臟負荷,並可能掩蓋早期反應。選項 C(僅在輸血開始和結束時測量生命徵象)是不夠的,輸血初期(前 15 分鐘)是反應最常見的發生時機,需要密切監測。選項 A(經由中央靜脈導管輸血)並非絕對必要,周邊靜脈亦可,重點在於確保輸血安全。
Ensuring proper identification of the client and the blood product is the most critical step in preventing ABO incompatibility and other life-threatening transfusion reactions. This process typically involves a double-check by two qualified healthcare providers to verify patient identity, medical record number, blood type, Rh factor, and unit details. Frequent vital sign monitoring during the initial phase of the transfusion is also essential to detect early signs of adverse reactions.
無顯著差異。輸血安全的核心原則,特別是輸血前的雙重身份與血品核對,在台灣與美國的醫療機構中均為標準作業程序(SOP)。兩地都會嚴格執行此步驟,以最大程度地降低輸血相關風險。