病人正接受靜脈輸注氯化鉀 20 mEq/100 mL 生理食鹽水。護理師觀察到哪項發現時需立即停止輸注？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. Which assessment finding requires the nurse to immediately stop the infusion?
- ASwelling and coldness at the catheter insertion site✓ 正解導管插入處腫脹且發冷
- BHeart rate of 88 beats per minute心率每分鐘 88 次
- CSerum potassium level of 4.2 mEq/L血清鉀濃度 4.2 mEq/L
- DPatient reports mild burning at the IV site病人報告靜脈注射處有輕微灼熱感
氯化鉀具有強烈刺激性，若發生滲漏（Extravasation）會造成組織壞死。選項 A 描述了典型的滲漏症狀（腫脹、冷感）。選項 D 的輕微燒灼感為輸注常見現象，可藉由減慢速率改善。鉀離子 4.2 是正常範圍，心率 88 亦在正常範圍內，無需停藥。
Potassium chloride is highly irritating, and extravasation can cause tissue necrosis. Option A describes typical signs of infiltration (swelling and coolness at the site). The mild burning in option D is a common infusion-related sensation that can be relieved by slowing the rate. A potassium level of 4.2 mEq/L is within the normal range, and a heart rate of 88 bpm is also normal; neither requires stopping the infusion.
台美兩地對於鉀離子滲漏處置皆為立即停止並評估局部組織，但美國護理師更強調滲漏後的藥物解毒劑評估與介入。