— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈輸注氯化鉀 40 mEq，護理師發現注射部位冰涼且腫脹。此時最優先的護理措施為何？
A client is receiving an intravenous infusion of potassium chloride 40 mEq in 1000 mL 0.9% Normal Saline. The nurse notes the IV site is cool and swollen. What is the priority nursing action?
- AApply a warm compress to the site在注射部位進行熱敷
- BStop the infusion and remove the catheter✓ 正解停止輸注並拔除導管
- CAssess for a blood return評估是否有血液回流
- DSlow the rate of the infusion減慢輸注速率
— Explanation · 中文詳解 —
此臨床表現提示滲漏（Infiltration）。由於氯化鉀具有刺激性，一旦發生滲漏可能導致組織壞死，必須立即停止輸注並移除導管，保護周邊組織，並依據機構指引進行後續處理（如抬高肢體或冷熱敷），避免嚴重的化學性傷害。
This clinical presentation suggests infiltration. Because potassium chloride is an irritant, once infiltration occurs it can cause tissue necrosis; the infusion must be stopped immediately and the catheter removed to protect the surrounding tissue. Subsequent care (such as limb elevation or warm/cold compresses) should follow institutional guidelines to prevent severe chemical injury.
✦ 台美臨床差異
台美兩地對於化學性藥物滲漏的處理原則一致，均強調保護組織避免壞死，台灣護理師通常需向醫師回報並記錄滲漏範圍與處理細節。