病人正接受靜脈輸注氯化鉀 20 mEq 於 100 mL 生理食鹽水中，護理師觀察到輸注部位紅腫且溫熱。護理師的首要行動為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the site is red, swollen, and warm to the touch. What is the nurse's priority action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BFlush the intravenous line沖洗靜脈導管
- CApply a warm compress to the area在該部位敷熱敷
- DSlow the infusion rate減慢輸注速率
此臨床表現為靜脈炎（phlebitis）或藥物外滲。氯化鉀具刺激性，若發生滲漏或靜脈炎，首要目標是終止對周邊組織的進一步傷害。先行停止輸注能避免藥物繼續對血管內皮造成發炎反應或組織壞死，後續再進行移除導管與評估血管狀況。
This clinical picture represents phlebitis or drug extravasation. Potassium chloride is highly irritating; when leakage or phlebitis occurs the priority is to stop further injury to the surrounding tissue. Stopping the infusion first prevents the drug from continuing to cause inflammation or tissue necrosis in the vascular endothelium; only then should the catheter be removed and the vasculature assessed.
美台臨床對於輸注部位紅腫處置一致，皆以停止輸注並移除導管為首要處置。