— 降低風險 · HARD · MCQ —
護理師照護一位接受化學治療的病人，發現注射部位出現紅腫。護理師優先採取什麼行動？
A nurse is caring for a client who is receiving intravenous (IV) chemotherapy. The nurse notices redness and swelling at the site. What is the nurse's priority action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BApply a cold compress to the site在注射部位應用冷敷
- CAspirate any remaining medication from the tubing從管路中抽吸剩餘藥物
- DNotify the physician通知醫師
— Explanation · 中文詳解 —
化療藥物多具備發泡性（vesicant），若發生滲漏（extravasation），第一要務是立即停止輸注（A），以防止更多藥物進入組織。之後才是移除管路並根據藥物特性進行冷熱敷或注射解毒劑。C 是後續，C 在停止輸注後進行，但停止本身是關鍵。
Many chemotherapy agents are vesicants; with suspected extravasation, the first priority is to stop the infusion immediately (A) to prevent further drug entry into tissues. The line is then disconnected and care follows drug-specific protocols (cold/warm compress, antidote). C comes after; D occurs after the infusion is stopped—but stopping itself is the key initial action.
✦ 台美臨床差異
美國化療規範極強調化療護理師的專業認證，台灣則在各級醫院對化療滲漏處理流程要求一致。