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降低風險 · MEDIUM · SATA

護理師正在為病人進行靜脈輸注氯化鉀(KCl)。為預防併發症,護理師應評估下列哪些項目?(選所有適合的)

A nurse is caring for a client who is receiving intravenous potassium chloride. Which of the following findings should the nurse assess for to prevent complications? (Select all that apply.)

  • AAdequacy of urine output✓ 正解
    尿量的充足程度。
  • BIV site for phlebitis or infiltration✓ 正解
    靜脈注射部位是否有靜脈炎或滲漏。
  • CSerum potassium levels✓ 正解
    血清鉀離子濃度。
  • DCardiac rhythm✓ 正解
    心律。
  • EPeripheral capillary refill time
    周邊毛細血管回填時間。
Explanation · 中文詳解

氯化鉀具有高度刺激性且過量會致死,必須嚴格監測。尿量不足會導致鉀離子滯留造成高血鉀;輸注部位若滲漏會造成組織壞死;監測血鉀確保在治療範圍;心律監測則是因為鉀離子異常會引發致命性心律不整。微血管回填時間與此處置無直接關聯。

Potassium chloride is highly irritating and can be fatal in overdose, so it must be strictly monitored. Inadequate urine output causes potassium retention and hyperkalemia; extravasation at the infusion site causes tissue necrosis; monitoring serum potassium ensures it stays within the therapeutic range; cardiac monitoring is required because potassium abnormalities can trigger lethal dysrhythmias. Capillary refill time is not directly related to this intervention.

✦ 台美臨床差異

美國多數機構規定高濃度 KCl 須經中央靜脈投予;台灣常由週邊靜脈給予但需加強稀釋。

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