病人獲醫囑給予靜脈輸注氯化鉀 20 mEq。護理師在給藥前必須採取的關鍵行動為何？
A client is prescribed intravenous potassium chloride 20 mEq. Which action by the nurse is essential before administering this medication?
- AAssess the client's hourly urine output✓ 正解評估病人的每小時尿量
- BDilute the medication in 500 mL of normal saline將藥物稀釋於 500 mL 生理鹽水中
- CVerify the medication with another nurse與另一位護理師核對藥物
- DCheck the client's blood glucose level檢查病人的血糖水平
鉀離子主要透過腎臟排泄，若尿量不足（<30 mL/hr）表示腎功能可能受損，此時給予鉀離子極易導致致命性的高血鉀症。因此，確認腎功能與尿量是給予鉀劑的安全護理基石。C 選項為雙重簽核，雖是常規步驟，但安全性評估優先於流程確認。B 選項錯誤在於鉀劑濃度通常需限制，不能隨意稀釋於過大體積。
Potassium is excreted primarily by the kidneys. Inadequate urine output (< 30 mL/hr) suggests possible renal impairment, in which case administering potassium can readily cause life-threatening hyperkalemia. Therefore, confirming renal function and urine output is the safety foundation of nursing care for potassium administration. Option C (double verification) is a routine step, but safety assessment takes precedence over procedural confirmation. Option B is incorrect because potassium concentration is restricted and cannot be diluted into an arbitrarily large volume.
美台皆需嚴格監測腎功能與濃度，但台灣對靜脈鉀劑給藥有更嚴謹的護理指導原則，常限制必須走獨立管線。