病人正接受靜脈輸注 20 mEq 氯化鉀於 100 mL 生理食鹽水中。護理師發現輸注部位發紅、溫熱且腫脹。優先採取的護理措施為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the infusion site is red, warm, and swollen. What is the priority nursing action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BSlow the rate of infusion減慢輸注速率
- CFlush the intravenous line to clear the obstruction沖洗靜脈管路以清除阻塞
- DApply a cold compress to the site在注射部位應用冷敷
此徵象顯示靜脈炎（Phlebitis）或外滲（Infiltration）。氯化鉀具有高度刺激性，若發生外滲會導致組織壞死，必須立即停止輸注以防止藥物繼續對血管周邊造成嚴重化學性損傷。後續步驟為移除管路並評估受損程度，絕對不可為了測試回血而嘗試沖洗。
These signs suggest phlebitis or infiltration. Potassium chloride is highly irritating; if extravasation occurs, it can cause tissue necrosis. The infusion must be stopped immediately to prevent further chemical injury to the surrounding tissue. Subsequent steps include removing the IV catheter and assessing the extent of injury. The line should never be flushed in an attempt to test for blood return.
美台臨床對於鉀離子滴注規範相似，皆強調外滲後需立即停止，但美國護理師常需負責評估是否需要通報藥師採取藥物解毒劑（如 Phentolamine）。