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一位患有心臟衰竭與慢性腎臟病的老年人，因症狀性貧血被開立 2 單位紅血球，且無活動性出血。完成計畫以降低並因應輸血相關循環超載風險。

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The nurse should first ::선택::assume that chronic heart failure does not affect transfusion riskplan to infuse both units rapidly before reassessmentidentify high TACO risk and collaborate on a single-unit-then-reassess strategywithhold all blood without notifying the prescriber, administer blood using ::선택::the fastest rate the intravenous catheter permitsthe ordered controlled rate with close respiratory and volume-status monitoringgravity flow without a timing devicea rate chosen by the client without reference to policy or prescription, and if new dyspnea, hypertension, crackles, or hypoxemia develops, ::선택::stop the transfusion, position upright as tolerated, support ABCs, notify, and follow the reaction protocolcontinue the transfusion and reassess after the second unitlower the head of bed and encourage oral fluidsdocument an expected finding without notifying the transfusion service.

護理師應先 ::선택::假設慢性心臟衰竭不影響輸血風險計畫在再評估前快速輸注兩單位辨識高 TACO 風險並合作進行單一單位後再評估策略未通知開立醫囑者即停止所有輸血，使用 ::선택::靜脈導管可容許的最快速度醫囑的受控速度，並密切監測呼吸與體液狀態不使用計時裝置的重力滴注由個案自行選擇且不參考政策或醫囑的速度 輸注血液，若出現新的呼吸困難、高血壓、囉音或低血氧，則 ::선택::停止輸血、盡可能協助坐起、支持 ABC、通知並遵循反應處理流程繼續輸血並在第二單位後再評估降低床頭並鼓勵口服液體記錄為預期發現，不通知輸血部門。

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