病人正在靜脈輸注氯化鉀（KCl），護理師發現注射部位腫脹、觸感冰冷且蒼白。下列哪些是優先採取的行動？（選所有適合的）
A client is receiving an IV infusion of potassium chloride. The nurse notices the IV site is swollen, cool to the touch, and pale. What is the priority nursing action? (Select all that apply.)
- AStop the infusion immediately✓ 正解立即停止輸注
- BApply a cold compress to the site在注射部位應用冷敷
- CRemove the peripheral IV catheter✓ 正解移除周邊靜脈導管
- DElevate the affected extremity✓ 正解抬高受影響的肢體
- EAdminister an antidote as ordered依醫囑給予解毒劑
此症狀顯示氯化鉀發生滲漏（Infiltration）。KCl 具高刺激性，若滲漏會導致組織壞死。首要步驟是立即停止輸注並拔除管路。抬高肢體可協助組織吸收滲出的液體並減輕水腫。冷敷在氯化鉀滲漏時不適用（可能加重血管收縮或不適），應依循機構指引進行熱敷或特定處置。
These symptoms indicate infiltration of potassium chloride. KCl is highly irritating, and extravasation can cause tissue necrosis. The first step is to stop the infusion immediately and remove the IV line. Elevating the limb helps the tissues to absorb the extravasated fluid and reduces edema. Cold compresses are not appropriate for KCl infiltration (they may worsen vasoconstriction or discomfort); the facility's specific guidelines for warm compresses or other interventions should be followed.
美國護理師常有權直接處理血管通路事件，台灣則需視醫院政策是否允許護理師直接移除滲漏點而無須醫師先行評估。