— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正接受氯化鉀（KCl）靜脈滴注，主訴注射部位有灼熱感。護理師應先採取哪項行動？
A client is receiving an intravenous infusion of potassium chloride. The client reports burning at the IV site. Which action should the nurse take first?
- ASlow the infusion rate減慢輸注速率
- BStop the infusion and assess the site✓ 正解停止輸注並評估注射部位
- CApply a cold compress to the site在注射部位敷冷敷
- DNotify the healthcare provider通知醫療保健提供者
— Explanation · 中文詳解 —
氯化鉀對血管具有高度刺激性，灼熱感可能是靜脈炎（Phlebitis）或藥液外滲（Extravasation）的徵象。護理師首要行動是停止輸注並評估部位有無紅腫、滲漏。若確認外滲，需立即處理以防組織壞死。減慢流速雖可減輕刺激，但若已外滲則無效且危險。
Potassium chloride is highly irritating to vessels; burning may indicate phlebitis or extravasation. The first nursing action is to stop the infusion and assess the site for redness, swelling, or leakage. If extravasation is confirmed, prompt intervention prevents tissue necrosis. Slowing the rate is insufficient if extravasation has occurred.
✦ 台美臨床差異
美國 NCLEX 非常強調對刺激性藥物（Vesicants）外滲的即時反應；台灣臨床上 KCl 稀釋濃度與流速限制亦有嚴格規範。