— 降低風險 · HARD · MCQ —
護理師準備靜脈輸注氯化鉀，給藥前最優先的評估項目為何？
A nurse is preparing to administer potassium chloride IV. Which assessment is the priority before starting the infusion?
- AUrine output in the last 24 hours✓ 正解過去 24 小時的尿量
- BCurrent serum potassium level目前血清鉀濃度
- CPresence of a patent IV site靜脈通路是否暢通
- DThe patient's cardiac rhythm病人的心律
— Explanation · 中文詳解 —
給予鉀離子（KCl）前，最嚴格的生理安全門檻是「腎功能」。鉀離子主要透過腎臟排泄，若病人尿量不足（<30 mL/hr），代表腎臟排泄功能受損。若此時仍給予 KCl，極易導致嚴重的「高血鉀」，甚至引發致命性心律不整。因此，給藥前確認尿量是護理師最重要的安全評估步驟。其他評估雖重要，但腎功能是鉀離子給藥的絕對禁忌關鍵。
Assessing urine output is the priority before administering intravenous potassium because the kidneys are responsible for its excretion. Administering potassium to a client with oliguria or anuria can lead to life-threatening hyperkalemia and cardiac arrhythmias. While serum levels and cardiac rhythm are important, ensuring adequate renal function is the critical safety prerequisite.