— 降低風險 · HARD · MCQ —
護理師準備靜脈輸注氯化鉀（KCl）。下列哪項護理動作對安全至關重要？
A nurse is preparing to administer intravenous potassium chloride. Which nursing action is essential for safety?
- ACheck the client's blood pressure every 5 minutes每 5 分鐘測量病患血壓
- BVerify that the client has adequate urine output✓ 正解確認病患有足夠的尿液排出量
- CAdminister the potassium as a rapid IV push快速靜脈推注鉀離子
- DAdminister the medication without diluting it不稀釋直接給藥
— Explanation · 中文詳解 —
靜脈輸注 KCl 是高警訊藥物（High-alert medication）。在給予前必須確保病人腎功能正常（尿量 >30 mL/hr），否則會導致高血鉀危及心臟。KCl 絕對不能以 IV push 給予（會導致心跳停止），且必須稀釋後給藥。監測心電圖比監測血壓更為重要。
Intravenous KCl is a high-alert medication. Before administration, the nurse must verify that the client has adequate renal function (urine output > 30 mL/hr); otherwise, hyperkalemia may develop and threaten cardiac function. KCl must never be given by IV push (which can cause cardiac arrest), and it must be diluted before infusion. Continuous ECG monitoring is more important than blood pressure monitoring.
✦ 台美臨床差異
兩國皆視 KCl 為高警訊藥物，嚴格執行給藥前雙人核對與尿量監測。