— 降低風險 · HARD · MCQ —
護理師準備對病人進行 20 mEq 氯化鉀 IV 推注。下列何者為優先護理措施？
A nurse is preparing to administer potassium chloride 20 mEq IV bolus to a client. What is the priority nursing action?
- AQuestion the order due to safety protocols✓ 正解基於安全協議質疑該醫囑
- BVerify the concentration and rate with a second nurse與第二位護理師確認濃度和速率
- CAdminister the medication slowly over 1 hour在1小時內緩慢給藥
- DAssess the IV site for infiltration評估靜脈穿刺部位是否有滲漏
— Explanation · 中文詳解 —
氯化鉀絕對不能以 IV 推注（Push/Bolus）方式給藥，極易導致心律不整甚至心跳停止。護理師首要任務是質疑並拒絕此類危險醫囑，以維護病人安全。即便稀釋給藥，也必須經由中央靜脈或設定嚴格輸注速率。
Potassium chloride must never be given as an IV push (bolus); doing so easily causes arrhythmias and even cardiac arrest. The nurse's first task is to question and refuse such a dangerous order to maintain patient safety. Even when diluted, KCl must be administered through a central line or with strictly controlled infusion rates.
✦ 台美臨床差異
台美醫療倫理皆嚴格禁止 KCl 靜脈推注，美國常見於護理師權限內直接拒絕，台灣環境若遇到，應立即聯絡醫師修改處方。