— 降低風險 · MEDIUM · MCQ —
護理師準備對低血鉀病人靜脈輸注氯化鉀，給藥前最優先的評估項目為何？
A nurse is preparing to administer potassium chloride IV to a client with hypokalemia. Which of the following assessments is a priority before administration?
- AMonitoring the client's blood glucose level監測病患的血糖水平
- BChecking the client's blood pressure檢查病患的血壓
- CAssessing the client's respiratory rate評估病患的呼吸頻率
- DVerifying the presence of urine output✓ 正解確認是否有尿液排出
— Explanation · 中文詳解 —
鉀離子主要透過腎臟排出，若病人無尿（anuria）或尿量極少，給予鉀離子會迅速導致嚴重高血鉀，誘發致命性心律不整。因此在靜脈給予鉀離子前，必須確認腎臟功能運作正常且有足夠尿量輸出（一般要求 > 30 mL/hr）。
Potassium is primarily excreted by the kidneys. If the client is anuric or has very low urine output, administering potassium can rapidly lead to severe hyperkalemia and life-threatening dysrhythmias. Therefore, before IV potassium administration, the nurse must confirm that renal function is intact and that urine output is adequate (generally >30 mL/hr).
✦ 台美臨床差異
美國護理師對靜脈給鉀有嚴格的濃度與速率限制（例如不得大於 10mEq/hr）；台灣醫院護理常規通常亦有相同安全性規範。