護理師照護一位接受持續靜脈輸注的病人。護理師發現注射部位摸起來冰涼、腫脹，且病人主訴不適。護理師的首要行動是什麼？
A nurse is caring for a client with a continuous intravenous infusion. The nurse notices the insertion site is cool to the touch, swollen, and the client reports discomfort. What is the nurse's first action?
- ASlow the infusion rate to see if the swelling subsides減慢輸注速率，以觀察腫脹是否消退
- BApply a warm compress to the site在患處應用熱敷
- CElevate the affected extremity抬高受影響的肢體
- DStop the infusion and remove the catheter✓ 正解停止輸注並拔除導管
病人描述的症狀（皮膚冰涼、腫脹、不適）是典型的「靜脈外滲/浸潤」（Infiltration）。這發生在導管移位，導致非刺激性藥液進入皮下組織時。處理外滲的首要步驟永遠是「停止輸注並移除導管」，以防止更多液體進入組織造成壓迫或損傷。B 選項（熱敷）和 C 選項（抬高）是移除導管後的後續護理措施（需視藥物性質選擇冷/熱敷）；A 選項錯誤，因為液體已經不在血管內，減慢速度無濟於事。在 NCLEX 考試中，發現併發症時的「Stop the source」原則是判斷首選行動的關鍵。這題考查基礎靜脈輸液護理的安全管理。
The client's findings (skin cool to the touch, swelling, discomfort) are classic signs of IV infiltration. This occurs when the catheter dislodges and non-vesicant fluid enters the subcutaneous tissue. The first step in managing infiltration is always to 'stop the infusion and remove the catheter,' to prevent additional fluid from entering the tissue and causing compression or injury. Option B (warm compress) and Option C (elevation) are follow-up nursing measures after catheter removal (and warm/cold compresses should be chosen based on the medication); Option A is incorrect because the fluid is no longer in the vessel and slowing the rate will not help. In the NCLEX exam, the 'stop the source' principle is the key to identifying the priority action when a complication is detected. This question tests basic safety management of intravenous infusion.
美國護理對於 Infiltration 與 Extravasation（強效藥物外滲）區分極嚴。如果是腐蝕性藥物（Vesicant），移除前可能需回抽藥液。台灣臨床流程相似，但此題考的是一般 Infiltration，重點在於「果斷拔除」的護理介入。