— 降低風險 · MEDIUM · MCQ —
護理師準備為病人靜脈輸注氯化鉀（KCl）。下列哪項是護理師的首要行動？
A nurse is preparing to administer potassium chloride intravenous piggyback to a client. Which action is the priority for the nurse?
- ACheck the client's most recent serum creatinine level檢查病人最近的血清肌酸酐值
- BAssess the client's urine output prior to administration✓ 正解給藥前評估病人之尿量
- CEnsure the medication is diluted according to facility policy確保藥物依機構政策稀釋
- DVerify that the client has a patent peripheral IV line確認病人之周邊靜脈通路暢通
— Explanation · 中文詳解 —
給予鉀離子前，必須確認腎功能足以代謝該劑量，以防高血鉀導致心律不整。若病人無尿（anuria）或尿量過少，鉀離子蓄積會造成致命風險。其他選項雖然重要，但確認腎排泄功能是保障病人安全的最關鍵指標，遵循「No Pee, No K」的原則。
Before administering potassium, the nurse must confirm that renal function is sufficient to excrete the dose in order to prevent hyperkalemia-induced cardiac dysrhythmias. If the patient is anuric or has very low urine output, potassium will accumulate and pose a lethal risk. Although the other options are also important, verifying renal excretory function is the most critical safety check, following the principle of "No Pee, No K."
✦ 台美臨床差異
台灣醫院常有嚴格的給藥前確認清單（checklist），美國則更依賴護理師的臨床判斷與電子醫囑系統的即時警示。