護理師正準備為低血鉀病人靜脈注射氯化鉀（KCl）。下列哪些護理措施對用藥安全至關重要？（選所有適合的）
The nurse is preparing to administer an intravenous dose of potassium chloride to a client with hypokalemia. Which nursing action is essential for safety? (Select all that apply.)
- AAdminister the potassium via IV push經靜脈推注給予鉀離子
- BEnsure the infusion rate does not exceed 10 mEq/hr✓ 正解確保輸注速率不超過 10 mEq/hr
- CMonitor the client's urine output during therapy✓ 正解治療期間監測個案的尿液排出量
- DDilute the potassium in at least 100 mL of fluid✓ 正解將鉀離子稀釋於至少 100 mL 的液體中
- EPlace the client on a continuous cardiac monitor✓ 正解將個案連接至連續性心臟監測器
靜脈補充鉀離子是一項高警訊（High-alert）的護理行為。首先，絕對嚴禁 IV push（A），這會導致瞬間心臟停搏。正確做法必須是稀釋後緩慢滴注（D）。通常在一般病房，滴注速度不可超過 10 mEq/hr（B），在加護病房且有密切監測下才可能提高至 20 mEq/hr。由於鉀主要經由腎臟排泄，若尿量不足（<30 mL/hr），鉀會快速累積導致高血鉀，因此監測尿量（C）極其重要。最後，血鉀波動會影響心臟傳導，連續心電圖監測（E）是及早發現心律不整（如 T 波高尖）的關鍵。這題考驗護理師對於電解質補充的極限值與監測重點。遺漏任何一項安全措施都可能對病人造成傷害。
Intravenous potassium replacement is a high-alert nursing activity. First, IV push administration is absolutely prohibited (A), as it can produce immediate cardiac arrest. The correct method is to dilute the dose and infuse it slowly (D). On a general unit, the infusion rate must not exceed 10 mEq/hr (B), and only in an intensive care unit under close monitoring can it potentially be increased to 20 mEq/hr. Because potassium is primarily eliminated by the kidneys, an inadequate urine output (<30 mL/hr) allows potassium to accumulate quickly and produce hyperkalemia, so monitoring urine output (C) is critical. Finally, fluctuations in serum potassium affect cardiac conduction, so continuous ECG monitoring (E) is essential for early detection of dysrhythmias (such as peaked T waves). This question tests the nurse's understanding of limits and monitoring priorities for electrolyte replacement. Omission of any one safety measure can harm the client.
在美國，10 mEq/hr 是病房的標準上限。台灣部分臨床單位在嚴重低鉀時可能依醫囑在有監視器下用到 20 mEq/hr，但 NCLEX 考試中 10 mEq/hr 是最穩定的安全標準。