— 降低風險 · HARD · MCQ —
護理師準備對一位低血鉀病患進行靜脈輸注氯化鉀，下列哪項評估為優先？
A nurse is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which assessment is the priority?
- AReviewing the client's most recent glucose level檢視病人最近的血糖值
- BMonitoring the infusion site for phlebitis監測輸注部位的靜脈炎跡象
- CChecking the client's hourly urine output✓ 正解檢查病人每小時的尿量
- DAssessing the client's bowel sounds評估病人的腸鳴音
— Explanation · 中文詳解 —
鉀離子主要透過腎臟排出。若病患尿量不足（<30 mL/hr），代表腎功能可能受損，此時補鉀極易導致致命性的高血鉀症。護理師必須確認腎功能正常（尿量足夠）後，才可安全給予鉀離子。其他選項雖重要，但未達到維持生命安全的優先級別。
Potassium is excreted primarily by the kidneys. If urine output is inadequate (<30 mL/hr), renal function may be impaired, and supplementing potassium under such conditions can lead to lethal hyperkalemia. The nurse must verify adequate renal function (sufficient urine output) before safely administering potassium. The other options are important, but do not reach the priority level required for life safety.
✦ 台美臨床差異
美國護理師常依護理常規確認尿量；台灣則多需由醫師評估後開立給藥醫囑。