— 降低風險 · MEDIUM · MCQ —
護理師準備為病人靜脈點滴輸注氯化鉀，下列哪項護理措施對病人安全最重要？
A nurse is preparing to administer potassium chloride intravenous piggyback to a client. Which nursing action is most critical for patient safety?
- AEnsure the medication is diluted in a large volume of solution✓ 正解確保藥物稀釋於大量溶液中
- BCheck that the client has a peripheral IV site only確認病人僅有周邊靜脈留置針
- CMonitor the site for signs of hematoma監測穿刺部位是否有血腫跡象
- DAdminister the potassium as a rapid IV bolus快速靜脈推注氯化鉀
— Explanation · 中文詳解 —
氯化鉀具有極強的刺激性，嚴禁直接靜脈推注（Bolus），必須進行充分稀釋。高濃度鉀離子進入血管會引起劇烈疼痛，甚至導致心律不整或心臟驟停。護理師必須核對醫囑濃度與稀釋液體量，確保輸注速度符合安全規範。
Potassium chloride is highly irritating, and direct IV bolus is strictly prohibited; the medication must be adequately diluted. Highly concentrated potassium entering a blood vessel causes severe pain and can lead to dysrhythmias or even cardiac arrest. The nurse must verify the ordered concentration and the volume of diluent and ensure that the infusion rate complies with safety standards.
✦ 台美臨床差異
台美皆嚴禁鉀離子推注，但美國護理師常有藥物稀釋的協定，台灣則多由藥局調配完成後直接掛點滴。