— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師正在為病人靜脈注射氯化鉀，下列哪種觀察應促使護理師立即停止輸注？
A nurse is administering a dose of intravenous potassium chloride to a client. Which observation should prompt the nurse to discontinue the infusion immediately?
- APatient complains of mild phlebitis at the insertion site病人主訴穿刺部位有輕微靜脈炎
- BPatient reports pain and swelling at the infusion site✓ 正解病人報告輸注部位疼痛及腫脹
- CUrine output is 40 mL/hr尿量為 40 mL/hr
- DHeart rate is 78 beats per minute心率为 78 次/分鐘
— Explanation · 中文詳解 —
氯化鉀具有極強的刺激性，若發生滲漏（Extravasation）會對周圍組織造成嚴重壞死，因此一旦病人出現注射部位疼痛或腫脹，應立即停止給藥以防止組織損傷。A選項雖需處理但不如滲漏緊急，C與D選項均在正常臨床監測範圍內。
Potassium chloride is highly irritating; extravasation can cause severe necrosis of surrounding tissue. Once the patient reports pain or swelling at the injection site, the administration must be stopped immediately to prevent tissue injury. Option A also requires action but is not as urgent as extravasation, and options C and D fall within normal clinical monitoring parameters.
✦ 台美臨床差異
台美臨床對於高濃度鉀離子給藥皆採取嚴格監測，美國護理師常須確認心電圖監測，台灣則強調藥物外滲後的緊急沖洗處置。