病人接受靜脈輸注氯化鉀 20 mEq/100 mL，時間為 1 小時。下列哪項評估結果需要立即採取護理行動？
A client is receiving an intravenous infusion of potassium chloride 20 mEq/100 mL over 1 hour. Which assessment finding requires immediate nursing intervention?
- ASerum potassium level of 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
- BPatient complains of burning at the IV site✓ 正解病人抱怨靜脈注射部位有灼熱感
- CBlood pressure of 128/82 mmHg血壓為 128/82 mmHg
- DHeart rate of 88 beats per minute心率為每分鐘 88 次
氯化鉀具有強烈刺激性，若發生注射部位燒灼感，極可能發生血管滲漏（infiltration）或靜脈炎，必須立刻停止輸注以防組織壞死。鉀離子過快進入周邊靜脈會導致嚴重的血管傷害，護理重點在於監測管路通暢度，燒灼感是臨床最警示的徵兆，優先等級遠高於生命徵象監測。
Potassium chloride is highly irritating; burning at the infusion site likely indicates infiltration or phlebitis and the infusion must be stopped immediately to prevent tissue necrosis. Rapid entry of potassium into peripheral veins can cause severe vascular injury. Nursing care emphasizes monitoring catheter patency; burning is the most alarming clinical sign, with priority higher than vital signs monitoring.
美國護理師常依政策評估輸液滲漏風險；台灣常見使用中央靜脈管路輸注鉀離子以減少周邊刺激，但發生滲漏時處置原則一致。