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藥理與非經腸給藥 · MEDIUM · MCQ

病人正在靜脈輸注 20 mEq 氯化鉀於 100 mL 生理食鹽水中。護理師發現注射部位冰冷、蒼白且腫脹,優先護理措施為何?

A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the IV site is cool, pale, and swollen. What is the priority nursing action?

  • AAssess for a blood return in the catheter
    評估導管是否有血液回流
  • BSlow the infusion rate
    減慢輸注速度
  • CStop the infusion immediately✓ 正解
    立即停止輸注
  • DApply a warm compress to the site
    在注射部位敷熱敷包
Explanation · 中文詳解

氯化鉀(Potassium Chloride)是一種高警訊藥物(High-alert medication),具有強烈的組織刺激性。題幹描述的「冰冷、蒼白、腫脹」是典型的靜脈滲漏(Infiltration)徵象。若藥液持續滲入周邊組織,可能導致嚴重的組織損傷甚至壞死。因此,第一優先動作必須是立即停止輸液以遏止進一步損傷。

Potassium chloride is a high-alert medication with a strong tissue-irritant effect. The findings described — coolness, pallor, and swelling at the site — are classic signs of IV infiltration. If the medication continues to infiltrate the surrounding tissue, it can cause severe tissue damage or even necrosis. Therefore, the first priority is to stop the infusion immediately in order to prevent further injury.

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