— 降低風險 · HARD · MCQ —
護理師準備對一位低血鉀病人靜脈給予氯化鉀（KCl），下列哪項護理措施最重要？
A nurse is preparing to administer potassium chloride (KCl) IV to a client with hypokalemia. Which of the following is the most important nursing intervention?
- ACheck the IV site for infiltration✓ 正解檢查靜脈注射部位是否有滲漏
- BDilute the medication in at least 100 mL of fluid將藥物稀釋於至少100 mL液中
- CMonitor urinary output every hour每小時監測尿液排出量
- DVerify the patient's potassium level before infusion輸注前確認病人的血鉀值
— Explanation · 中文詳解 —
KCl 是高警訊藥物且極具刺激性。若輸注過程發生滲漏，會導致嚴重的組織壞死與化學性燒傷。因此，確保靜脈通路通暢（A）是預防局部嚴重併發症的首要任務。尿量（C）在輸注後追蹤以評估腎功能，但非防範滲漏風險的當下步驟。
KCl is a high-alert medication and is highly irritating. If infiltration occurs during infusion, it can cause severe tissue necrosis and chemical burns. Therefore, ensuring IV patency (A) is the foremost task in preventing serious local complications. Urine output (C) is monitored after infusion to assess renal function, but it is not the immediate step for preventing infiltration risk.
✦ 台美臨床差異
美國護理師常需自行計算 drip rate 並對高警訊藥物雙人核對；台灣多由藥局調配好預混液，給藥前須確認管路。