— 藥理與非經腸給藥 · HARD · MCQ —
病人正以 1 小時內輸注 20 mEq 氯化鉀的速度接受點滴。下列哪項評估結果需要護理師立即介入？
A client is receiving an intravenous infusion of potassium chloride 20 mEq/100 mL over 1 hour. Which assessment finding requires immediate intervention by the nurse?
- APatient reports mild burning at the infusion site病人報告輸注部位有輕微灼熱感
- BPatient reports palpitations and shortness of breath✓ 正解病人報告心悸與呼吸困難
- CSerum potassium level is 4.2 mEq/L血清鉀濃度為4.2 mEq/L
- DInfusion pump alarm indicating completion of dose輸注幫浦警報顯示劑量已輸注完畢
— Explanation · 中文詳解 —
靜脈輸注氯化鉀過快或濃度過高會引發致命性心律不整。心悸與呼吸困難可能是高鉀血症引發的心臟傳導異常跡象，應立即停止輸注並進行心電圖監測。輕微灼熱感常見於鉀離子輸注，可減慢速度，但心臟症狀優先於局部不適。
Potassium chloride infusions can cause life-threatening cardiac dysrhythmias if administered too rapidly or in excessive amounts. Palpitations and shortness of breath are critical signs of hyperkalemia affecting cardiac conduction and require immediate cessation of the infusion and further medical evaluation. While mild burning at the site is common, cardiac symptoms take precedence as they indicate systemic toxicity.
✦ 台美臨床差異
美國護理師常需依據心電圖異常自行決定停止輸注，台灣臨床對於氯化鉀給藥通常有嚴格的心電圖監測醫囑規範。