護理師正在監測一名靜脈注射氯化鉀的病人。護理師發現注射部位發紅且輕微腫脹。優先採取的行動是什麼？
A nurse is monitoring a client receiving an intravenous infusion of potassium chloride. The nurse notes the insertion side is red and slightly swollen. What is the priority action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BSlow the rate of the infusion減慢輸注速率
- CElevate the extremity抬高患肢
- DApply a cold compress to the site在注射部位應用冷敷
靜脈輸注氯化鉀（Potassium chloride）時，注射部位出現發紅和輕微腫脹是靜脈滲漏（infiltration）或靜脈炎（phlebitis）的典型徵象。氯化鉀是一種具有刺激性的藥物，若滲漏至組織間隙，可能導致嚴重的組織損傷，甚至壞死。護理師在此情境下的首要任務是確保病人安全，立即停止輸液以防止進一步的組織損害，並評估傷害程度，再採取適當的後續措施。 正確答案「立即停止輸液」是基於病人安全與傷害預防的考量。若持續輸注刺激性溶液，將使組織損傷加劇。停止輸液後，才能安全地進行後續處理，例如移除靜脈導管、評估滲漏等級、應用冷熱敷或注射解毒劑（若有需要）。這是依照臨床判斷的優先順序：停止造成傷害的源頭，保護病人。
When infusing potassium chloride IV, redness and slight swelling at the insertion site are typical signs of infiltration or phlebitis. KCl is a vesicant; extravasation into tissue can cause severe tissue damage or necrosis. The nurse's first priority is to ensure patient safety by stopping the infusion immediately to prevent further tissue injury and then assessing the extent of harm before further actions. Stopping the infusion first is the priority based on patient safety and harm prevention. Continued infusion of an irritating solution worsens tissue damage. Only after stopping can the nurse safely remove the catheter, grade the infiltration, apply cold or warm compresses, or give an antidote if indicated. The clinical priority is to remove the source of harm to protect the patient.