病人正在靜脈輸注氯化鉀 20 mEq(稀釋於 100 mL 生理食鹽水)。護理師發現輸液部位發紅且疼痛。護理師應優先採取何種措施?
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the infusion site is erythematous and painful. Which action is the priority?
- ANotify the physician通知醫師
- 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在輸注部位敷熱敷包
氯化鉀(KCl)屬於高警訊藥物,具有強烈的組織刺激性。當輸注部位出現紅腫、疼痛時,應高度懷疑外滲(Infiltration)或靜脈炎。氯化鉀外滲會導致組織壞死、嚴重水腫甚至神經損傷。根據護理安全原則,一旦懷疑藥物外滲,首要動作是立即停止輸注,以阻斷刺激性藥物持續進入皮下組織,隨後再進行評估與處置(如回抽殘餘藥物、移除管路)。
Potassium chloride (KCl) is a high-alert medication with strong tissue irritation. When the infusion site shows redness, swelling, or pain, infiltration or phlebitis should be strongly suspected. Extravasation of potassium chloride can cause tissue necrosis, severe edema, and even nerve injury. According to nursing safety principles, the first action when extravasation is suspected is to stop the infusion immediately to prevent the irritant from continuing to enter the subcutaneous tissue, followed by assessment and management (such as aspirating residual drug and removing the line).