一位持續滴注氯化鉀溶液的病人，護理師優先評估下列哪項發現？
A nurse is caring for a client with a continuous intravenous infusion of potassium chloride. Which assessment finding is most important for the nurse to prioritize?
- APotassium level of 4.2 mEq/L鉀離子濃度 4.2 mEq/L
- BPeripheral IV site showing mild redness周邊靜脈注射部位呈現輕微紅腫
- CClient report of dry mouth個案主訴口乾
- DUrine output of 20 mL/hour for the past 2 hours✓ 正解過去 2 小時尿量為 20 mL/小時
鉀離子（Potassium）主要經由腎臟排泄。當病人接受持續性的靜脈輸注氯化鉀（KCl）時，腎功能是預防高血鉀（hyperkalemia）毒性的最重要指標。若尿量（urine output）不足，代表腎臟排泄功能受損，鉀離子將滯留於體內，進而引發致命的心律不整。在 NCLEX 的臨床情境中，護理師需遵循「安全優先」原則，給予排鉀藥物前，必須確認腎臟代謝功能是否正常。尿量少於 30 mL/hr 通常被視為腎灌流不足或腎功能異常的警訊，必須立即評估並停止給藥。
Potassium is excreted primarily by the kidneys. When the client receives a continuous IV infusion of potassium chloride (KCl), renal function is the most important indicator for preventing hyperkalemic toxicity. If urine output is inadequate, renal excretion is impaired and potassium will accumulate in the body, potentially provoking fatal dysrhythmias. In NCLEX clinical scenarios, the nurse must follow the principle of safety first: before administering potassium-removing medications, renal function must be verified. A urine output of less than 30 mL/hr is generally considered a warning sign of inadequate renal perfusion or abnormal renal function, requiring immediate evaluation and cessation of the drug.
在美國臨床實務中，對於靜脈輸注高濃度鉀離子，通常有嚴格的監測規範（如使用輸液幫浦及頻繁監測心電圖），且對尿量的監測標準極為嚴格，護理師若發現尿量低於 30 mL/hr，通常會直接依據 protocol 暫停給藥並回報。