護理師準備為病人靜脈注射 20 mEq 氯化鉀，哪項措施是護理師的優先重點？
A nurse is preparing to administer potassium chloride 20 mEq IV piggyback to a client. Which action is the priority for the nurse?
- AVerify the patient's urine output is at least 30 mL/hr✓ 正解確認病人的尿液輸出量至少為 30 mL/hr
- BAssess the client's current serum potassium level評估客戶當前的血清鉀濃度
- CEnsure the medication is diluted in at least 100 mL of fluid確保藥物稀釋於至少 100 mL 的液體中
- DCheck the IV site for signs of infiltration檢查靜脈穿刺處是否有滲漏跡象
給予鉀離子前，必須確認腎功能足以排除多餘鉀離子以防高血鉀。每小時尿量需大於 30 mL 是最基本安全閥，若腎功能受損給鉀恐致心律不整。雖然其他選項亦屬安全規範，但在「給藥前」的生理參數評估中，腎功能排泄指標最為關鍵。
Before administering potassium, it is essential to confirm that renal function is adequate to excrete excess potassium and prevent hyperkalemia. Hourly urine output greater than 30 mL is the most basic safety threshold; administering potassium when renal function is impaired may lead to dysrhythmias. Although the other options are also part of safety standards, in pre-administration physiologic assessment, the renal excretion indicator is the most critical.
美國醫院系統常有明確的「No Urine, No Potassium」政策，台灣臨床護理師同樣落實，但電子醫囑系統更常見強制防呆提醒。