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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。輸注過程中哪項護理評估最關鍵?

A client is receiving an intravenous infusion of potassium chloride 20 mEq. Which nursing assessment is critical during the infusion?

  • AMonitor for urinary output
    監測尿液排出量
  • BAssess the IV site for infiltration✓ 正解
    評估靜脈注射部位是否有滲漏
  • CMonitor for respiratory distress
    監測是否有呼吸困難
  • DCheck the client's blood pressure every 15 minutes
    每15分鐘測量病人血壓
Explanation · 中文詳解

氯化鉀(KCl)屬於高警訊藥物(High-Alert Medication),具有強烈的組織刺激性。若發生靜脈滲漏(Infiltration)或外滲(Extravasation),會導致嚴重的組織發炎、壞死甚至潰瘍。因此,輸注過程中必須嚴密監測靜脈管路(IV site)的完整性。臨床上應確保管路通暢、無紅腫、無疼痛,若懷疑滲漏應立即停止輸注並依醫囑處理。

Potassium chloride (KCl) is a high-alert medication and is highly irritating to tissues. If venous infiltration or extravasation occurs, severe tissue inflammation, necrosis, and even ulceration may result. Therefore, the integrity of the IV site must be closely monitored throughout the infusion. Clinically, the line must remain patent, without redness, swelling, or pain; if infiltration is suspected, the infusion must be stopped immediately and managed according to the physician's order.

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