— 藥理與非經腸給藥 · EASY · MCQ —
病人正在靜脈滴注氯化鉀 20 mEq 溶於 100 mL 生理食鹽水。護理師發現注射部位紅腫。護理師的首要行動為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes redness and swelling at the site. What is the nurse's priority action?
- ASlow the infusion rate減慢輸注速率
- BStop the infusion immediately✓ 正解立即停止輸注
- CApply a cold compress to the area在該部位應用冷敷
- DNotify the healthcare provider通知醫療提供者
— Explanation · 中文詳解 —
氯化鉀（KCl）為高刺激性藥物，注射部位出現紅腫提示可能發生靜脈炎或外滲（infiltration）。一旦發現，護理師的首要行動是「立即停止輸注」（B），以防止組織進一步損傷甚至壞死。停止後再評估部位、拔除管路並依機構流程處置（如冷敷、通報醫師）。其他選項：A 減慢速度無法解決外滲；C 冷敷雖可減輕不適但需先停藥；D 通報醫師為後續步驟。
Redness and swelling at the infusion site suggest infiltration or extravasation of potassium chloride, which is highly irritating to tissues. The priority action is to stop the infusion immediately to prevent further tissue damage, followed by assessment and notification of the provider.