— 降低風險 · MEDIUM · MCQ —
護理師準備對低血鉀病人靜脈給予氯化鉀。給藥前最關鍵的評估指標為何？
A nurse is preparing to administer potassium chloride IV to a client with hypokalemia. Which nursing assessment is critical prior to administration?
- ACheck the client's deep tendon reflexes檢查病人的深層肌腱反射
- BMonitor the client's skin turgor監測病人的皮膚張力
- CAssess the client's current blood pressure評估病人的目前血壓
- DConfirm the client has an hourly urine output of at least 30 mL✓ 正解確認病人每小時尿量至少為 30 mL
— Explanation · 中文詳解 —
靜脈給予氯化鉀（Potassium chloride）具有高度危險性，因為鉀離子主要經由腎臟代謝。若病人腎功能受損或處於少尿狀態，給予鉀離子會導致血鉀濃度迅速飆升，引發致命性的心律不整（如心室顫動）。因此，在給予靜脈鉀離子前，確保病人的腎功能正常且排尿量達標（每小時至少 30 mL）是給藥前最重要的安全評估。
IV potassium chloride is high-risk because potassium is excreted primarily by the kidneys. If renal function is impaired or urine output is low, IV potassium can rapidly increase serum potassium and cause fatal arrhythmias such as ventricular fibrillation. Confirming adequate urine output (at least 30 mL/hr) is the most critical pre-administration assessment.