— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人獲醫囑給予靜脈注射氯化鉀 20 mEq，護理師給藥前應優先採取哪項措施？
A client is prescribed intravenous potassium chloride (KCl) 20 mEq. Which action is the priority for the nurse to perform before administration?
- AAssess the client's current urine output✓ 正解評估病人目前的尿量
- BDilute the medication in 100 mL of normal saline將藥物稀釋於100 mL的生理食鹽水中
- CVerify the peripheral IV site for patency確認周邊靜脈穿刺部位的暢通性
- DCheck the client's serum creatinine level檢查病人的血清肌酸酐值
— Explanation · 中文詳解 —
靜脈給予鉀離子前，必須確保腎功能正常且有足夠的尿量。若病人出現無尿或寡尿，靜脈注射鉀離子極易導致致命性的高血鉀與心律不整。雖然靜脈管路暢通（C）與稀釋（B）也很重要，但排尿情況是決定是否安全給藥的先決條件。
Before administering intravenous potassium, the nurse must ensure that renal function is intact and urine output is adequate. If the client is anuric or oliguric, IV potassium can readily cause lethal hyperkalemia and cardiac dysrhythmias. Although IV patency (C) and dilution (B) are also important, urinary status is the prerequisite for determining safe administration.
✦ 台美臨床差異
台美均強調鉀離子給藥的腎功能評估，美國護理師常需更嚴格依據 protocol 判斷尿量門檻。