— 降低風險 · EASY · MCQ —
一位病人正在接受氯化鉀靜脈輸液，護理師觀察到注射部位紅腫。護理師應優先採取哪項措施？
A client is receiving an IV infusion of potassium chloride. The nurse observes redness and swelling at the site. Which action should the nurse take first?
- ASlow the infusion rate減慢輸液速率
- BStop the infusion✓ 正解停止輸液
- CNotify the physician通知醫師
- DApply a warm compress施加熱敷
— Explanation · 中文詳解 —
氯化鉀（KCl）屬於高警訊藥物，具有強烈的組織刺激性。當輸液部位出現紅腫，提示可能發生了靜脈外滲（Extravasation/Infiltration）。此時，護理師的優先處置是立即停止輸注，以防止鉀離子進一步滲入皮下組織造成嚴重的組織壞死或化學性燒傷。在 NCLEX 考試中，處理潛在或已發生的組織損傷，優先級永遠高於通知醫師或嘗試其他緩解措施。
Potassium chloride is a high-alert medication that causes severe tissue necrosis if it extravasates. The nurse must immediately stop the infusion to prevent further tissue damage before notifying the provider or applying compresses.