— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人獲開立靜脈注射氯化鉀 20 mEq。在給藥前，護理師的優先護理措施為何？
A client is prescribed intravenous potassium chloride 20 mEq via IV piggyback. What is the priority nursing action before administration?
- AVerify the potassium level in the last lab report查驗最後一份檢驗報告中的鉀離子數值
- BCheck the client's blood pressure測量病人的血壓
- CAssess the client's urine output✓ 正解評估病人的尿量
- DEnsure the IV site is in a central line確保靜脈通路位於中心靜脈導管
— Explanation · 中文詳解 —
給予鉀離子前，腎功能檢查最為關鍵，因為鉀離子主要透過腎臟代謝。若病人無尿或少尿，給予鉀離子會導致高血鉀危險。雖然 C 也重要，但若腎臟無法代謝，即使數值正常也可能產生積累。A 確保排除腎功能衰竭引起的高鉀風險。
Before potassium administration, renal function tests are the most critical, because potassium is excreted mainly by the kidneys. If the patient is anuric or oliguric, administering potassium can produce dangerous hyperkalemia. Although A is also important, if the kidneys cannot excrete potassium, accumulation may occur even when baseline values are normal. A ensures that renal failure-related hyperkalemia risk is ruled out.
✦ 台美臨床差異
美國護理師常執行鉀離子輸注，台灣對高濃度鉀離子給予更嚴格的雙人核對與給藥路徑規範。