— 照護管理 · MEDIUM · MCQ —
護理師正照護一位靜脈輸注氯化鉀的病人。護理師發現靜脈注射部位紅、熱、腫。護理師優先採取什麼行動？
A nurse is managing a client who is receiving intravenous potassium chloride. The nurse notices the IV site is red, warm, and swollen. What is the priority nursing action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BApply a cold compress to the site在注射部位冷敷
- CSlow the rate of infusion減慢輸注速率
- DAssess the capillary refill time評估毛細血管再充盈時間
— Explanation · 中文詳解 —
氯化鉀具有高度刺激性，若發生滲漏（Infiltration/Extravasation），第一要務是停止輸注以防止組織損傷加劇。後續再評估、拔針並通知醫師。若不停止輸注會導致嚴重的化學性靜脈炎或組織壞死。
Potassium chloride is highly irritating. If infiltration or extravasation occurs, the first priority is to stop the infusion to prevent further tissue damage; the IV is then reassessed, removed, and the physician notified. Failure to stop the infusion can lead to severe chemical phlebitis or tissue necrosis.
✦ 台美臨床差異
在美國臨床，護理師有權立即停止輸液再報備；台灣護理師常需先確認醫囑或評估後執行，但遇化學性刺激滲漏均有權停止。