— 藥理與非經腸給藥 · MEDIUM · MCQ —
一位病人正接受 20 mEq 氯化鉀（KCl）靜脈輸注。下列哪項評估發現需要護理師立即停止輸注？
A client is receiving an intravenous infusion of potassium chloride (KCl) 20 mEq. Which assessment finding requires the nurse to stop the infusion immediately?
- AClient states they need to urinate病人表示需要排尿
- BBlood pressure is 120/80 mmHg血壓為 120/80 mmHg
- CHeart rate is 88 beats per minute心率为 88 次/分
- DClient reports burning at the IV site✓ 正解病人報告靜脈注射部位有燒灼感
— Explanation · 中文詳解 —
靜脈輸注氯化鉀（KCl）為高警訊藥物且具強烈血管刺激性。若輸注部位出現燒灼感（burning），代表已發生藥物外滲（infiltration）或靜脈炎（phlebitis），KCl 一旦外滲至皮下組織會造成嚴重的化學性組織壞死，必須立即停止輸注並重新建立靜脈通路。選項 A（想解尿）為腎臟對鉀離子排泄的正常生理反應；選項 C（心率 88 bpm）與選項 B（血壓 120/80）皆為正常生命徵象，不需停藥。
Potassium chloride is highly irritating to veins, and burning at the infusion site indicates infiltration or phlebitis. Immediate discontinuation is required to prevent severe tissue necrosis caused by extravasation, whereas normal vital signs and the urge to void do not necessitate stopping the infusion.