— 降低風險 · MEDIUM · SATA —
護理師準備給予病人靜脈滴注氯化鉀。需採取哪些預防措施？（多選）
A nurse is preparing to administer potassium chloride IV infusion to a client. Which precautions should the nurse take? (Select all that apply.)
- AVerify that the infusion rate does not exceed 10 mEq/hr via peripheral line✓ 正解確認經周邊靜脈輸注速率不超過 10 mEq/hr
- BAssess the IV site frequently for signs of infiltration or phlebitis✓ 正解經常評估靜脈注射部位是否有滲出或靜脈炎的跡象
- CAdminister the medication via IV push to ensure therapeutic levels透過靜脈推注給藥以確保治療濃度
- DEnsure the client is producing an adequate amount of urine✓ 正解確保病人有產生足夠的尿液
- EDilute the medication properly according to facility protocol✓ 正解依照機構規定適當稀釋藥物
— Explanation · 中文詳解 —
鉀離子具有強烈刺激性，靜脈給藥必須嚴格執行稀釋與限速。絕對不可直接靜脈推注（IV Push），否則會導致心律不整甚至心跳停止。給藥前須確認腎功能（尿量），確保鉀離子能經由腎臟排出，避免高血鉀導致致命風險。
Potassium chloride is a vesicant and must be properly diluted and administered via infusion, never as an IV push, to prevent cardiac arrest and tissue necrosis. The nurse must verify adequate urine output to ensure renal excretion and monitor the IV site for infiltration, while limiting the peripheral infusion rate to no more than 10 mEq/hr to prevent hyperkalemia.
✦ 台美臨床差異
美台臨床皆嚴格禁止 IV Push，但在給藥前確認尿量的臨床標準兩地皆一致。