NurslixJournal
藥理與非經腸給藥 · MEDIUM · MCQ

病人接受氯化鉀靜脈輸液時,主訴注射部位有燒灼感。護理師應優先採取的行動為何?

A client receiving an intravenous infusion of potassium chloride reports a burning sensation at the IV site. Which action should the nurse take first?

  • ASlow the rate of infusion
    減慢輸注速率
  • BCheck for blood return in the IV line
    檢查靜脈導管是否有血液回流
  • CApply a cold compress to the site
    在注射部位應用冷敷
  • DStop the infusion immediately✓ 正解
    立即停止輸注
Explanation · 中文詳解

氯化鉀(KCl)具有極高的化學刺激性,若發生滲漏(infiltration)或外滲(extravasation),會對周邊組織造成嚴重損傷,甚至導致組織壞死。當病人主訴燒灼感時,護理的第一優先級(Priority)是防止損傷擴大,因此必須立刻停止輸液(Stop the infusion)。此為安全護理的黃金準則,不可嘗試減速或觀察。

Potassium chloride (KCl) is highly chemically irritating. If infiltration or extravasation occurs, it causes severe tissue injury and even necrosis. When the client reports burning, the nursing priority is to prevent further damage by stopping the infusion immediately. This is the golden rule of safety; do not slow the rate or watch and wait.

✦ 台美臨床差異

在美國臨床執業中,護理師對高警訊藥物(High-alert medications)的處理極為嚴謹。一旦發生疑似滲漏,除立刻停止外,後續應依據機構政策(Protocol)執行移除導管並評估是否需要冷/熱敷或給予解毒劑,這與台灣臨床強調的「立即反應」原則一致。

Related · 同分類的其他題目

More from Pharmacological & Parenteral

瀏覽全部 2,027 題 藥理與非經腸給藥 →
Jump to another chapter