— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正接受靜脈輸注氯化鉀 20 mEq 溶於 100 mL 生理食鹽水，護理師觀察到靜脈注射部位有紅腫現象。首要的護理措施是什麼？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes redness and swelling at the IV site. What is the priority nursing action?
- ADiscontinue the infusion immediately✓ 正解立即停止輸注
- BSlow the infusion rate to reduce irritation減慢輸注速度以減少刺激
- CAssess for distal pulses評估遠端脈搏
- DApply a warm compress to the site在注射部位應用熱敷
— Explanation · 中文詳解 —
氯化鉀具有極強的組織刺激性，一旦發生靜脈炎或滲漏（extravasation），最緊急的步驟是立即停止輸注以防進一步組織壞死。氯化鉀不可經由周邊血管快速推注，若發生滲漏應評估後採取對應處置，而非單純降速。
Potassium chloride is highly irritating to tissue. Once phlebitis or extravasation occurs, the most urgent step is to immediately stop the infusion to prevent further tissue necrosis. Potassium chloride must never be administered as a rapid peripheral IV push; if extravasation occurs, the appropriate response is to assess and intervene, not simply slow the rate.
✦ 台美臨床差異
美台臨床皆視氯化鉀外滲為緊急事件，但美國護理師常需依規範執行滲漏處理包（extravasation kit），台灣通常由醫師評估後處理。