病人正以重力滴注方式靜脈輸注 20 mEq 氯化鉀。護理師觀察到輸注部位腫脹、觸感冰冷且蒼白。護理師首要採取行動為何？
A client is receiving an IV infusion of Potassium Chloride 20 mEq in 100 mL of 0.9% Normal Saline via gravity. The nurse observes the IV site is swollen, cool to the touch, and pale. What is the priority nursing action?
- AStop the IV infusion immediately✓ 正解立即停止靜脈輸注
- BCheck for a blood return檢查是否有血液回流
- CSlow the IV infusion rate減慢靜脈輸注速率
- DApply a warm compress to the site在輸注部位應用熱敷
此徵象顯示氯化鉀發生了外滲（Infiltration/Extravasation）。氯化鉀具強刺激性，若進入周邊組織恐造成化學性靜脈炎或組織壞死。首要步驟是立即停止輸注以防更多藥物進入皮下組織，隨後拔除管路並依機構政策處理受損部位。
These signs indicate that the potassium chloride has infiltrated/extravasated. Potassium chloride is highly irritating, and if it enters peripheral tissue it may cause chemical phlebitis or tissue necrosis. The first step is to stop the infusion immediately to prevent more medication from entering the subcutaneous tissue, then remove the catheter and manage the injured site per institutional policy.
美台臨床皆視輸液外滲為需立即停止之緊急情況，特別是具高危險性的藥物如氯化鉀。