— 降低風險 · MEDIUM · MCQ —
護理師準備為低鉀血症病人靜脈輸注氯化鉀。下列何者為優先的護理措施？
A nurse is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which of the following is a priority nursing action?
- AEnsure the medication is diluted in at least 100 mL of fluid確保藥物稀釋於至少 100 mL 液中
- BAssess the client's blood pressure every 5 minutes每 5 分鐘評估病人血壓
- CCheck the client's urine output before infusion✓ 正解輸注前檢查病人尿量
- DAdminister the medication via IV push經靜脈推注給予藥物
— Explanation · 中文詳解 —
給予鉀離子前，必須確認腎功能正常，因鉀離子過量堆積會導致致命心律不整。觀察排尿狀況（至少 30 mL/hr）是評估腎功能的重要臨床指標。鉀離子絕對禁止靜脈推注，必須稀釋並透過輸液泵控制速度，且給予後應監測心電圖。
Before administering potassium, it is essential to confirm that renal function is intact, because excessive accumulation of potassium can cause lethal dysrhythmias. Monitoring urine output (at least 30 mL/hr) is a key clinical indicator of renal function. IV push of potassium is absolutely contraindicated; potassium must be diluted and administered via an infusion pump with rate control, and the ECG should be monitored after administration.
✦ 台美臨床差異
美國常規使用輸液泵設定，台灣在加護病房使用精確輸液泵監測較為嚴格。