— 藥理與非經腸給藥 · HARD · MCQ —
病人正接受 20 mEq 氯化鉀加入 100 mL 生理食鹽水的靜脈輸注。給藥前最重要的護理措施為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. What is the most critical nursing action before initiating the infusion?
- AObtain a baseline blood pressure reading取得基礎血壓讀數
- BAssess the client's current urine output✓ 正解評估客戶目前的尿液排出量
- CCheck the peripheral IV site for signs of phlebitis檢查周邊靜脈注射部位是否有靜脈炎跡象
- DVerify the concentration with another nurse由另一位護理師核對濃度
— Explanation · 中文詳解 —
給予鉀離子前，腎功能是首要考量。若病人無尿（anuria）或尿量不足，給予鉀離子會導致高血鉀，進而引發致命性心律不整。雖然鉀離子輸注需雙人核對（D），但在確保排泄途徑暢通前，評估腎功能是臨床安全的最高原則。
Before administering potassium, renal function is the foremost consideration. If the client is anuric or oliguric, administering potassium can result in hyperkalemia and precipitate fatal cardiac dysrhythmias. Although potassium infusions require a two-nurse double-check (D), assessing renal function to ensure that the excretion pathway is intact is the highest clinical-safety priority.
✦ 台美臨床差異
美台臨床皆視腎功能為鉀輸注首要條件，但美國常要求使用輸液幫浦，且針對高濃度鉀有嚴格的給藥禁忌規範。