— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人在靜脈輸注氯化鉀（KCl）過程中，下列哪項評估結果需要立即採取護理行動？
A client is receiving an intravenous infusion of potassium chloride (KCl). Which assessment finding requires immediate nursing intervention?
- ASerum potassium level of 4.2 mEq/L血清鉀濃度 4.2 mEq/L
- BComplaints of burning at the IV site✓ 正解主訴靜脈注射部位有灼熱感
- CUrine output of 25 mL/hour尿量 25 mL/小時
- DHeart rate of 82 beats per minute心率 82 次/分鐘
— Explanation · 中文詳解 —
KCl 是高警訊藥物，極具刺激性。若病人表示注射部位有灼熱感，暗示血管外滲可能，必須立即停止輸注並移除點滴，以免造成嚴重的局部組織壞死。尿量 25 mL/hr 雖偏低，但未達立即中斷輸液之緊急度。其餘數據均在正常範圍內。
KCl is a high-alert medication and is highly irritating. If the patient reports a burning sensation at the injection site, this suggests possible extravasation, and the infusion must be stopped and the IV removed immediately to avoid serious local tissue necrosis. A urine output of 25 mL/hr is somewhat low but does not reach the urgency required to immediately interrupt the infusion. The other findings are within normal limits.
✦ 台美臨床差異
美台皆將 KCl 列為高警訊藥物，台灣多要求由中央靜脈給予或嚴格稀釋，美國若使用周邊靜脈則對濃度限制更嚴。