病人正接受靜脈輸注 20 mEq 氯化鉀於 100 mL 生理食鹽水中，下列何種評估結果需護理師立即介入？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. Which assessment finding requires immediate nursing intervention?
- AThe IV bag has 50 mL remaining靜脈輸液袋剩餘 50 mL
- BPatient has a urine output of 40 mL/hour病人尿量為 40 mL/小時
- CPatient reports mild burning at the IV site✓ 正解病人報告靜脈注射部位有輕微灼熱感
- DSerum potassium level is 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
氯化鉀具有強烈刺激性，易導致周邊血管炎或組織壞死。若病人出現燒灼感，應立即停止輸注，檢查有無外滲（infiltration）。鉀離子濃度 4.2 屬正常範圍，尿量 40 mL/h 代表腎功能足夠排除鉀離子，輸注剩餘量屬正常過程，非緊急事件。
Potassium chloride is highly irritating and can readily cause peripheral phlebitis or tissue necrosis. If the client experiences a burning sensation, the infusion should be stopped immediately and the site checked for infiltration. A potassium level of 4.2 mEq/L is within the normal range; urine output of 40 mL/hr indicates adequate renal capacity to excrete potassium; and remaining fluid in the bag is a normal part of the infusion process, not an emergency.
美國護理師常需自行計算輸液滴數或幫浦設定；台灣臨床多由護理師操作幫浦，且對鉀離子濃度要求較為嚴謹，常見需稀釋後緩慢滴注。