一位病人正接受氯化鉀（KCl）靜脈點滴，出現哪種徵象需立即停止輸注？

核心概念：靜脈輸注氯化鉀（Potassium Chloride, KCl）的護理監測與安全。 為什麼正確答案 D 對：氯化鉀（KCl）溶液對靜脈組織具有強烈刺激性。若輸注過程中病人報告 IV 點有燒灼感（burning sensation），這極有可能是藥物滲漏（extravasation）或靜脈炎（phlebitis）的徵兆。KCl 滲漏至周圍組織會引起嚴重的組織壞死和疼痛。因此，出現此症狀時，護理師應立即停止輸注，移除 IV，並評估 IV 點周圍組織的狀況，及時處理以防止進一步損傷。 為什麼其他選項錯： B. 每小時 40 mL 的尿量（urine output）屬於正常範圍（一般認為正常成人每小時至少應有 30-50 mL 的尿量）。充足的尿量表示腎臟有足夠的灌流，能夠代謝並排出鉀離子，這對於輸注 KCl 是個好現象，表示病人有能力排除過量的鉀，無需停止輸注。 C. 血清鉀離子濃度為 4.2 mEq/L，這在正常範圍內（通常為 3.5-5.0 mEq/L）。這表示病人的電解質平衡穩定，輸注 KCl 並未導致高血鉀，因此無需停止。 D. 心率 78 bpm 處於正常範圍（60-100 bpm）。高血鉀（hyperkalemia）可能導致心律不整或心跳減慢，但此病人心率正常，顯示目前沒有高血鉀的跡象。 臨床思路：此題考量的是「藥物安全」與「不良反應的識別」。KCl 靜脈輸注有潛在的局部刺激性和全身性高血鉀風險。護理師需密切監測 IV 點的狀況及病人的心率與尿量，以便及時發現並處理不良反應。

Core concept: Nursing monitoring and safety of intravenous potassium chloride (KCl) infusion. Why correct answer D is right: Potassium chloride (KCl) solution is highly irritating to venous tissue. If during the infusion the client reports a burning sensation at the IV site, this is highly suggestive of drug extravasation or phlebitis. Extravasation of KCl into surrounding tissues can cause severe tissue necrosis and pain. Therefore, when this symptom appears, the nurse should immediately stop the infusion, remove the IV, assess the tissue around the IV site, and intervene promptly to prevent further damage. Why the other options are wrong: B. A urine output of 40 mL/hr is within the normal range (an adult should generally have at least 30-50 mL/hr). Adequate urine output indicates that the kidneys are receiving adequate perfusion and are able to metabolize and excrete potassium, which is a favorable sign for KCl infusion, indicating the client is able to excrete excess potassium, and the infusion does not need to be stopped. C. A serum potassium level of 4.2 mEq/L is within the normal range (typically 3.5-5.0 mEq/L). This indicates stable electrolyte balance, and the KCl infusion has not led to hyperkalemia, so it does not need to be stopped. D. A heart rate of 78 bpm is within the normal range (60-100 bpm). Hyperkalemia can cause dysrhythmias or bradycardia, but this client's heart rate is normal, showing no current evidence of hyperkalemia. Clinical reasoning: This question addresses medication safety and the recognition of adverse reactions. IV KCl infusion carries potential local irritant and systemic hyperkalemia risks. The nurse must closely monitor the IV site condition as well as the client's heart rate and urine output, so as to detect and manage adverse reactions promptly.