病人正在進行靜脈注射氯化鉀（KCl）。下列哪項觀察需護理師立即介入？
A client is receiving an intravenous infusion of potassium chloride. Which observation requires immediate nursing intervention?
- AThe client has a slight redness at the insertion site病人插管處有輕微紅腫
- BThe infusion pump is set to 20 mEq/hr輸注幫浦設定為 20 mEq/hr
- CThe client reports a burning sensation at the IV site✓ 正解病人報告靜脈注射部位有灼熱感
- DThe client's urine output is 40 mL/hr病人的尿液輸出量為 40 mL/hr
靜脈輸注氯化鉀（KCl）的標準速率為 10-20 mEq/hr（透過周邊靜脈），20 mEq/hr 屬於正常上限值，不需立即介入。本題需立即介入的是 B：IV 部位灼熱感（burning sensation）是 KCl 外滲（infiltration）或靜脈炎的早期徵象，KCl 對組織具高度刺激性，外滲可造成嚴重組織損傷甚至壞死，必須立即停止輸注並評估部位。其他選項：D. 尿量 40 mL/hr 屬正常（>0.5 mL/kg/hr）；D. 輕微紅斑屬於早期靜脈炎跡象需觀察但非緊急。
The standard IV potassium chloride (KCl) infusion rate is 10–20 mEq/hr via a peripheral line; 20 mEq/hr is at the upper limit of normal and does not require immediate intervention. The finding that requires immediate intervention in this item is B: a burning sensation at the IV site is an early sign of KCl infiltration or phlebitis. KCl is highly irritating to tissues, and infiltration can cause severe tissue damage and even necrosis. The infusion must be stopped immediately and the site assessed. Other options: C — urine output of 40 mL/hr is normal (>0.5 mL/kg/hr); D — mild redness is an early sign of phlebitis requiring observation but is not an emergency.
美國醫院針對高濃度電解質有嚴格輸注協議，通常需由兩名護理師確認，台灣同級醫院亦有類似高警訊藥物規範。