當進行氯化鉀（KCl）靜脈輸注時，下列哪些護理措施是正確的？（選所有適合的）
Which of the following nursing actions are appropriate when administering potassium chloride IV infusion? (Select all that apply.)
- AEnsure the concentration does not exceed 10 mEq/100 mL for peripheral lines✓ 正解確保周邊靜脈輸注的濃度不超過 10 mEq/100 mL
- BUse an infusion pump to regulate the flow rate✓ 正解使用輸液幫浦調節滴速
- CMonitor the site for signs of phlebitis or infiltration✓ 正解監測注射部位是否有靜脈炎或滲漏跡象
- DAdminister as an IV bolus push to ensure rapid effect以靜脈推注方式給藥以確保快速療效
- ECheck the client's urine output before initiating the infusion✓ 正解在開始輸注前檢查個案的尿液排出量
鉀離子是高警訊藥物，處理不當易導致致命性的心律不整。選項 A 正確，鉀離子對血管內膜刺激極大，周邊靜脈濃度不應過高。選項 B 強制要求使用輸液幫浦，因為即使是微小的流速偏差都可能導致高血鉀。選項 C 極為重要，由於鉀的刺激性，一旦外滲即會導致嚴重的組織壞死。選項 E 是關鍵邏輯，除非病人有足夠尿量（至少 30 mL/hr），否則禁用鉀，因為若腎臟無法排鉀，直接輸注會造成危險高血鉀。選項 D 為致命性錯誤，絕對嚴禁靜脈推注（IV Push），否則會導致心臟驟停。此題考查對電解質給藥安全原則的綜合應用。
Potassium is a high-alert medication and improper handling can readily produce fatal dysrhythmias. Option A is correct: potassium is highly irritating to the vascular intima, so peripheral IV concentrations must not be too high. Option B is required: an infusion pump must be used because even small variations in flow rate can result in hyperkalemia. Option C is critical: due to potassium's irritant properties, extravasation causes severe tissue necrosis. Option E is a key principle—unless the client has adequate urine output (at least 30 mL/hr), potassium is contraindicated, because if the kidneys cannot excrete potassium, direct infusion can produce dangerous hyperkalemia. Option D represents a fatal error: IV push is absolutely prohibited, as it would cause cardiac arrest. This question evaluates comprehensive application of safety principles for electrolyte administration.
美國醫院針對高警訊藥物有嚴格的雙人核對與軟體鎖定速率機制；台灣臨床雖有高警訊標籤，但部分小型醫療機構仍依靠傳統滴計數器，風險管理較依賴護理師個人經驗。