— 降低風險 · HARD · SATA —
一位病人正接受發泡劑（vesicant）藥物輸注。哪些徵象顯示發生了滲漏（extravasation）？（選所有適合的）
A client is receiving an IV infusion of a vesicant drug. Which findings indicate extravasation? (Select all that apply.)
- ABurning pain at the site✓ 正解局部有灼熱痛
- BSwelling around the insertion site✓ 正解插入點周圍腫脹
- CCoolness of the skin around the site✓ 正解局部周圍皮膚發涼
- DBlood backflow upon checking the tubing檢查管路時有血液回流
- ELack of blood backflow✓ 正解無血液回流
— Explanation · 中文詳解 —
發泡劑（Vesicant）藥物若滲漏至皮下組織，會引發嚴重的組織壞死。護理師必須熟悉滲漏的徵象以便及時停止輸注。常見徵象包括注射部位出現灼熱感、腫脹、皮膚變涼（因藥物刺激導致血管收縮或組織浸潤），以及最客觀的指標：無法從導管抽回血液（Blood backflow）。若能抽回血液，通常代表導管末端仍在血管內。
Signs of extravasation include burning pain, swelling, coolness at the site, and inability to aspirate blood. These indicators suggest the vesicant has leaked into subcutaneous tissue, requiring immediate cessation of the infusion to prevent tissue necrosis.