病人靜脈注射氯化鉀 20 mEq 於 100 mL 生理食鹽水中，護理師發現輸液部位紅腫且溫熱。優先處置為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the site is red, swollen, and warm to the touch. What is the priority nursing action?
- AStop the infusion and remove the catheter✓ 正解停止輸注並拔除導管
- BSlow the infusion rate減慢輸注速率
- CApply a warm compress to the site在注射部位應用熱敷
- DFlush the catheter with normal saline以生理食鹽水沖洗導管
本題核心為靜脈注射併發症之緊急處理。氯化鉀（Potassium Chloride）具有極強的組織刺激性，若發生靜脈炎或滲漏（Infiltration/Extravasation），藥物會直接對周邊血管與組織造成化學性損傷，嚴重時導致組織壞死。優先處置原則為「移除刺激源」，即刻停止輸液並移除導管，以阻斷化學傷害持續擴大，隨後再評估血管狀況或進行傷口護理。
The core issue in this item is emergency management of an intravenous infusion complication. Potassium chloride is highly irritating to tissue, and if phlebitis or infiltration/extravasation occurs, the drug will directly cause chemical injury to peripheral vessels and tissues, leading in severe cases to tissue necrosis. The priority is to remove the source of irritation: immediately stop the infusion and remove the catheter to halt further chemical damage. Subsequent assessment of the vessel or wound care can follow.