醫師開立靜脈注射氯化鉀 20 mEq 的醫囑，護理師為了病人安全最重要採取的行動為何？
A client is prescribed intravenous potassium chloride 20 mEq. Which of the following nursing actions is most important for patient safety?
- ADilute the medication in at least 100 mL of fluid將藥物稀釋於至少100 mL的液體中
- BCheck the client's urine output before administration✓ 正解給藥前評估病人的尿量
- CMonitor the client's blood pressure every 5 minutes每5分鐘監測病人的血壓
- DAdminister the dose as a rapid IV push快速靜脈推注給藥
氯化鉀具有高度危險性，若給藥前腎功能不佳（如尿量不足），可能導致嚴重的急性高血鉀，進而引起心律不整甚至心跳停止。因此，確認腎臟排泄功能（尿量）是否正常，是給予鉀離子補充前的核心安全門檻。雖然稀釋（A）是必要的給藥技術，但在安全性優先級中，確認生理上的代謝能力（腎功能）排在第一位。快速推注（D）是絕對禁忌，會造成心臟傳導系統的致命抑制。監測血壓（C）對高血鉀雖有幫助，但心電圖監測及尿量監測才是針對鉀離子給藥的核心指標。此題考驗護理師對電解質安全閾值的判斷，特別是『無尿不補鉀』的黃金原則。
Potassium chloride is highly dangerous. If renal function is inadequate (low urine output) before administration, severe acute hyperkalemia and fatal arrhythmias can occur. Therefore, confirming adequate renal excretion (urine output) is the core safety threshold before potassium supplementation. While dilution (A) is a necessary administration technique, in safety priority order, confirming physiological metabolic capacity (renal function) comes first. Rapid IV push (D) is absolutely contraindicated and causes fatal cardiac conduction depression. BP monitoring (C) helps but ECG and urine output monitoring are the core indicators for potassium administration. This question tests judgment on electrolyte safety thresholds, especially the golden rule: 'no urine, no potassium.'
美國護理指引對高警訊藥物（High-Alert Medications）有嚴格的雙人核對制；台灣目前大型醫院多導入條碼給藥系統（BCMA）與電子醫囑審查，在給予高濃度電解質時，護理師對於尿量的評估習慣更為依賴護理紀錄，但兩者對於鉀離子給藥皆有嚴格規範。