病人正接受靜脈輸注氯化鉀（20 mEq/100 mL 生理食鹽水）。護理師發現注射部位冰冷、蒼白且腫脹。首要的護理措施為何？
A client is receiving an IV infusion of Potassium Chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the IV site is cool, pale, and swollen. What is the priority nursing intervention?
- AAssess the capillary refill評估毛細血管再充盈時間
- BStop the infusion immediately✓ 正解立即停止輸注
- CSlow the infusion rate減慢輸注速率
- DApply a warm compress to the site在注射部位應用熱敷
本題涉及靜脈輸液併發症評估。氯化鉀（KCl）屬於高警訊藥物（High-alert medication），具有強烈的組織刺激性。當導管發生滲漏（Infiltration）時，藥物會進入周圍組織而非血管內，這會導致化學性損傷、組織發炎甚至壞死。護理師首要任務是立即阻斷藥物進入組織，故「停止輸注」是保護病人的第一優先行動（Safety Priority）。隨後才會進行移除導管、評估循環與給予適當處理。
This item involves the assessment of IV complications. Potassium chloride (KCl) is a high-alert medication and is highly tissue-irritating. When infiltration occurs, the drug enters surrounding tissue instead of the vein, causing chemical injury, inflammation, and even necrosis. The nurse's first priority is to immediately stop the drug from entering tissue, so stopping the infusion is the first safety priority. Subsequent actions are catheter removal, circulation assessment, and appropriate treatment.
美方臨床對於KCl滲漏處理極為嚴格，通常要求立即停止輸注並移除導管，隨後依據機構Policy評估是否需給予特殊處理（如Phentolamine或冷敷）。台灣臨床亦強調停止輸注，但對於後續處置的標準化指引（Protocol）依各院規範差異較大。