病患醫囑給予 furosemide 40 mg IV push。下列哪項評估結果顯示護理師應暫緩給藥？
A client is prescribed furosemide 40 mg IV push. Which assessment finding requires the nurse to hold the medication?
- APeripheral edema 1+周邊水腫 1+
- BUrine output 40 mL/hr尿液排出量 40 mL/hr
- CBlood pressure 100/60 mmHg血壓 100/60 mmHg
- DSerum potassium 3.0 mEq/L✓ 正解血清鉀 3.0 mEq/L
Furosemide 屬於強效利尿劑，會導致鉀離子隨尿液大量流失。當血鉀濃度低於 3.5 mEq/L 時，給藥可能引發嚴重的心律不整。因此在給藥前確認電解質數值是護理師的專業職責。血壓 100/60 mmHg 尚在可接受範圍，尿量 40 mL/hr 亦屬正常，水腫則是給藥指標之一。
Furosemide is a potent loop diuretic that causes substantial urinary loss of potassium. When the serum potassium level falls below 3.5 mEq/L, administering the drug can precipitate serious cardiac arrhythmias. Therefore, verifying the electrolyte values before administration is a core professional responsibility of the nurse. A blood pressure of 100/60 mmHg is still within an acceptable range, a urine output of 40 mL/hr is also normal, and edema is one of the indications for giving the drug.
美國護理師可依據檢驗報告 protocol 判斷是否給藥，台灣多數單位需先聯繫醫師確認。