— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈輸注 100 mL 0.9% 生理食鹽水加 40 mEq 氯化鉀。護理師發現輸液部位紅腫、蒼白且觸感冰涼。護理師的首要行動為何？
A client is receiving an intravenous infusion of potassium chloride 40 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the infusion site is swollen, pale, and cool to the touch. What is the nurse's priority action?
- AApply a warm compress to the site to improve circulation在輸液部位敷熱敷以改善循環
- BFlush the intravenous line to check for patency沖洗靜脈管路以確認通暢
- CStop the infusion immediately and remove the catheter✓ 正解立即停止輸注並拔除導管
- DSlow the infusion rate to decrease tissue irritation減慢輸注速率以減少組織刺激
— Explanation · 中文詳解 —
此徵象顯示鉀離子發生滲漏（Infiltration/Extravasation）。氯化鉀具有強烈刺激性，若進入周邊組織會導致嚴重的組織壞死。首要措施是立即阻斷輸液來源，移除管路以防止更多藥物進入皮下組織，隨後需進行評估及處理。
These findings indicate infiltration/extravasation of potassium. KCl is a strong irritant; if it enters peripheral tissue it causes severe tissue necrosis. The priority action is to stop the infusion immediately and remove the catheter to prevent further drug entry into subcutaneous tissue, followed by site assessment and management.
✦ 台美臨床差異
美台臨床對於滲漏處理均要求立即停止輸注，但美系醫院常有針對鉀離子外滲的特定拮抗處理流程。