病人正在進行氯化鉀 20 mEq 的靜脈輸注。為確保病人安全,護理師必須執行哪項行動?
A client is receiving an intravenous infusion of potassium chloride 20 mEq. Which action by the nurse is essential to ensure client safety?
- AMonitor for hypertension監測高血壓
- BDiscontinue the infusion if the client reports nausea若病人報告噁心則停止輸注
- CAdminister the dose as an IV push以靜脈推注方式給藥
- DVerify the concentration and infusion rate✓ 正解確認濃度與輸注速率
氯化鉀(KCl)屬於高警訊藥物(High-alert medication)。由於鉀離子直接進入血液會導致心律不整甚至心臟驟停,因此絕對禁止靜脈直接推注(IV push)。護理師在給藥前必須嚴格確認輸液濃度(通常需稀釋)與輸注速率(不得超過每小時 10-20 mEq),並使用輸液幫浦(IV pump)控制滴速。
Potassium chloride (KCl) is a high-alert medication. Because potassium entering the bloodstream directly can cause cardiac dysrhythmias or even cardiac arrest, IV push administration is absolutely prohibited. Before administering the medication, the nurse must strictly verify the infusion concentration (which usually requires dilution) and the infusion rate (which must not exceed 10-20 mEq per hour), and use an IV pump to control the rate.
在台灣與美國,氯化鉀的 IV 給藥規定皆極為嚴格,護理師需具備「永不 IV Push 鉀」的臨床警覺。美國臨床常規中,使用幫浦(Pump)控制速率是標準流程,且通常會優先考慮由周邊靜脈稀釋輸注或使用中心靜脈導管。