護理師照顧一位正在靜脈輸注氯化鉀的病人。下列哪些發現需要立即介入？（選所有適合的）
A nurse is caring for a client receiving an IV infusion of Potassium Chloride. Which assessment findings require immediate intervention? (Select all that apply.)
- ABurning at the IV site during infusion✓ 正解輸注期間靜脈穿刺處有灼熱感
- BSerum potassium level of 5.2 mEq/L✓ 正解血清鉀濃度為 5.2 mEq/L
- CPatient reports feeling nauseated病人主訴感到噁心
- DUrine output of 20 mL/hr✓ 正解尿量為 20 mL/hr
- EECG showing peaked T waves✓ 正解心電圖顯示尖聳 T 波
IV KCl 極具刺激性。A（注射部位灼熱感）代表血管外滲或刺激；B（高血鉀）需停藥；D（尿量過少）若尿量不足 <30mL/hr，給鉀會增加腎臟負擔；E（T波尖聳）為高血鉀心電圖特徵，皆為急迫狀況。C（噁心）雖常見但非最危急。
Intravenous KCl is highly irritating. A (burning at the injection site) indicates extravasation or vessel irritation; B (hyperkalemia) requires the medication to be stopped; D (insufficient urine output) is a concern, as administering potassium with urine output below 30 mL/hr increases the renal burden; and E (peaked T waves) is the ECG hallmark of hyperkalemia. All of these are urgent situations. C (nausea) is common but is not the most urgent finding.
台灣醫院對於高濃度鉀離子輸注常設有專用標籤與雙人核對流程，這點與美國相同。