— 降低風險 · HARD · SATA —
病人獲醫囑以周邊靜脈點滴給予 20 mEq 氯化鉀。哪些護理措施能確保安全？（選所有適合的）
A client is prescribed IV potassium chloride 20 mEq via peripheral line. Which nursing action ensures safety? (Select all that apply.)
- AVerify that the medication is diluted in at least 100 mL of fluid✓ 正解確認藥物已稀釋於至少 100 mL 液中
- BAssess the patency of the peripheral IV site before administration✓ 正解給藥前評估周邊靜脈留置針通暢度
- CAdminister the dose as an IV bolus push以靜脈推注方式給予劑量
- DMonitor the infusion rate to not exceed 10 mEq/hour✓ 正解監控輸注速率，不超過 10 mEq/小時
- EEnsure the client is on a cardiac monitor if indicated by hospital policy✓ 正解若醫院政策指示，確保病人連接心電圖監測儀
— Explanation · 中文詳解 —
鉀離子具有強烈刺激性，嚴禁直接靜脈推注（Bolus），否則會引起心律不整及心跳停止。正確做法包括：稀釋給藥、確認靜脈路徑通暢避免滲漏導致壞死、嚴格控制滴速（通常不超過 10-20 mEq/hr）以及必要時進行心電圖監測。
Potassium ions are highly irritating, and IV push administration is strictly prohibited because it can cause cardiac dysrhythmias and cardiac arrest. The correct approach includes diluting the dose, verifying patency of the IV line to prevent infiltration and tissue necrosis, strictly controlling the infusion rate (generally not exceeding 10-20 mEq/hr), and applying cardiac monitoring when indicated.
✦ 台美臨床差異
美國護理師在給藥前常需過濾藥物資訊系統，台灣則依賴醫師處方與藥師雙重核對。