# 護理師準備給予1單位PRBC。哪一組輸注前作法對預防致命溶血反應最重要？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391882&lang=zh-tw  
> language: zh-TW  
> subject: Adverse Effects/Contraindications/Interactions  
> category: PPT

## 題目

護理師準備給予1單位PRBC。哪一組輸注前作法對預防致命溶血反應最重要？

## 選項

1. 將PRBC與D5W混合以減慢輸注
2. 兩名護理師在床邊確認個案身分（兩項識別）、血品ABO/Rh、單位號碼、效期與交叉配血；管路只使用生理食鹽水，不混入其他液體；慢速開始並在前15分鐘陪伴觀察 **✔ 正確答案**
3. 一名護理師默默檢查標籤
4. 不論監測狀況，所有單位都在1小時內輸完

**正確答案: 2**

## 解析

正確（2）：預防ABO不合需要兩名護理師床邊確認。比對個案兩項識別、血品ABO/Rh、單位號碼、效期、交叉配血結果。血品只能使用生理食鹽水（D5W會溶血，LR含Ca會凝血）。慢速開始，前15分鐘留在個案身邊，因嚴重反應多在15分鐘內發生。每單位需於4小時內完成。（1,3,4）危險。

## 深入解析

記憶提示 輸血4規則 =「2人確認、只用生食、慢速開始 + 15分鐘觀察、4小時上限」。生命徵象：輸前、15分鐘、1小時、結束。任何反應都停止並評估。

## 臨床情境

情境 有症狀貧血成人被開立PRBC 1單位。血品已自血庫取回。

## 重要概念

- **兩名護理師確認** — 床邊雙人確認身分與血品；預防ABO不合。
- **血品相容輸液** — 血品只能搭配生理食鹽水；D5W會溶血，LR會凝血。
- **輸血時間限制** — 每單位需於4小時內輸完，以避免細菌增殖。

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