護理師收到醫囑，要為一位低血鉀病人以靜脈推注（IV bolus／IV push）方式給予氯化鉀 20 mEq。護理師應先採取哪項行動？
A nurse receives an order to administer potassium chloride 20 mEq by IV bolus (IV push) to a client with hypokalemia. Which action should the nurse take first?
- ACheck the client's serum potassium level檢查病人的血清鉀離子濃度
- BHold the medication and contact the prescriber to clarify the order暫停給藥並聯絡開立醫囑者釐清醫囑正確答案
- CObtain an ECG strip取得心電圖條帶
- DAssess the patency of the IV site評估靜脈穿刺點的通暢性
- B暫停給藥並聯絡開立醫囑者釐清醫囑
氯化鉀是 ISMP 列管的高警訊藥品，FDA 仿單明文規定僅能「以校準過的輸液裝置、緩慢且受控的速率」靜脈輸注，絕對禁止 IV push（直接靜脈推注）——未經稀釋的鉀離子快速進入循環會造成致命性高血鉀，導致心律不整甚至心搏停止。因此護理師面對這張醫囑的第一步不是任何給藥前準備，而是暫停給藥並聯繫開立醫師澄清醫囑（選項 B）。選項 A 檢查血鉀值、C 取得心電圖、D 評估靜脈導管通暢度，在合法的氯化鉀輸注中都是必要環節，但若依原醫囑執行 IV push，這些準備動作沒有一項能降低推注本身的致命性，故都不是首要動作。臨床提醒：護理師對明顯不安全的醫囑負有質疑義務，不得逕行執行；常規輸注速率不應超過 10 mEq/hr，周邊靜脈給藥濃度一般不超過 40 mEq/L（依機構規範最高 80 mEq/L）。
- A檢查病人的血清鉀離子濃度
鉀離子濃度是醫師判斷用藥依據，護理師職責在於確保給藥途徑與速度正確，預防致命錯誤。
- B · 正確答案暫停給藥並聯絡開立醫囑者釐清醫囑
高濃度鉀離子快速進入體內會導致心臟驟停，確認稀釋濃度與速率是給藥的最核心安全門檻。
- C取得心電圖條帶
心電圖監測是用於發現異常，但在給藥前，物理性的劑量核對才是預防損害的第一道防線。
- D評估靜脈穿刺點的通暢性
靜脈導管通暢性雖重要，但相較於錯誤給藥造成的生命威脅，確認給藥安全更為優先。
兩地皆將鉀離子列為高警訊藥物（High-alert medication），台灣病人安全通報系統建議高警訊藥品給藥應有稽核機制（如雙重核對或其他結合資訊系統的方法），美國則依循嚴格的給藥安全條例。 台灣出處：財團法人醫院評鑑暨醫療品質策進會〈TPR警示訊息No.152：預防高警訊藥品給藥錯誤〉（2018）
English explanation
Option B is correct because the Institute for Safe Medication Practices classifies potassium chloride as a high-alert medication, and Food and Drug Administration labeling permits only slow intravenous infusion at a controlled rate through a calibrated infusion device; IV push administration is prohibited. Rapid entry of undiluted potassium into the circulation can cause fatal hyperkalemia, dysrhythmias, or cardiac arrest. The nurse must hold the medication and contact the prescriber to clarify the unsafe order before taking any medication-preparation step. Option A is incorrect because checking the serum potassium level does not reduce the lethal danger of IV push administration. Option C is incorrect because obtaining an ECG strip cannot make the ordered IV push safe. Option D is incorrect because confirming IV patency is necessary for a properly ordered potassium chloride infusion but does not address the danger in this order. Nurses must question clearly unsafe orders rather than carry them out. Routine infusion rates should not exceed 10 mEq/hr, and peripheral intravenous concentrations are generally limited to 40 mEq/L (up to 80 mEq/L per facility policy).
最近修訂：2026-10-05