— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈滴注氯化鉀，護理師觀察到注射部位紅腫且溫熱，應優先採取何種措施？
A client is receiving an intravenous infusion of potassium chloride. The nurse notes the site is red, warm, and swollen. What is the priority nursing action?
- AApply a cold compress to the site在注射部位應用冷敷
- BStop the infusion immediately✓ 正解立即停止輸注
- CIrrigate the IV line with normal saline以生理食鹽水沖洗靜脈通路
- DSlow the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
氯化鉀（Potassium chloride）是一種強烈的刺激性藥物（Vesicant）。若靜脈注射部位出現紅、腫、熱等徵象，顯示發生了滲漏（Infiltration）或外滲（Extravasation），藥物進入周邊組織將導致組織壞死。護理師應立即停止輸液，移除管路，評估受損程度，並依照醫療機構規範進行後續處置。
Potassium chloride is a strong vesicant. If the IV site develops redness, swelling, and warmth, it indicates infiltration or extravasation, and the medication entering surrounding tissue can cause tissue necrosis. The nurse should immediately stop the infusion, remove the catheter, assess the extent of damage, and follow the facility's protocol for subsequent management.