— 藥理與非經腸給藥 · EASY · MCQ —
病人正在接受靜脈輸注氯化鉀，護理師觀察到留置部位發紅與疼痛。護理師應優先採取何種措施？
A client is receiving an intravenous infusion of potassium chloride. The nurse notes redness and pain at the insertion site. Which action should the nurse take first?
- ANotify the physician通知醫師
- BSlow the infusion rate減慢輸注速率
- CDiscontinue the infusion✓ 正解停止輸注
- DApply a warm compress施加溫熱敷
— Explanation · 中文詳解 —
氯化鉀具有極強的組織刺激性，一旦出現靜脈炎或滲漏跡象（紅、腫、熱、痛），首要步驟是立即停止輸注以防止組織壞死。熱敷或減慢速度並不能解決已經發生的局部刺激。在移除輸液管路後，後續再評估是否需要更換注射部位或通知醫師。
Potassium chloride is highly irritating to tissues. Once signs of phlebitis or infiltration appear (redness, swelling, warmth, pain), the priority is to immediately discontinue the infusion to prevent tissue necrosis. Warm compresses or slowing the rate cannot resolve the local irritation that has already occurred. After removing the IV line, reassess the need to change the site or to notify the physician.
✦ 台美臨床差異
台美執業標準皆規定滲漏時應立即移除管路，但美國護理師在處置後記錄病歷的法律嚴謹度通常較高。