— 降低風險 · HARD · MCQ —
護理師準備為低血鉀病人靜脈輸注氯化鉀，下列哪項護理行動對於降低醫療傷害風險最為優先？
A nurse is preparing to administer potassium chloride intravenously to a client with hypokalemia. Which of the following is a priority nursing action to reduce the risk of harm?
- ACheck the client's urine output before initiating在開始輸注前檢查病人的尿液排出量
- BVerify the medication concentration and infusion rate✓ 正解確認藥物濃度和輸注速率
- CAssess the intravenous site for signs of phlebitis評估靜脈注射部位是否有靜脈炎的跡象
- DMonitor serum potassium levels every hour每小時監測血清鉀離子水平
— Explanation · 中文詳解 —
鉀離子注射濃度過高或速度過快，極易引發致命性的心律不整。這是高警訊藥物，護理師的首要責任是透過「三讀五對」確認濃度與給藥速度。尿量監測同樣重要，但相對於給藥安全細節，確保醫囑輸注速率是直接防止心搏停止的關鍵。
Rapid infusion or high concentrations of intravenous potassium can cause fatal cardiac arrhythmias, making verification of the medication concentration and infusion rate the priority nursing action. Although checking urine output and assessing the IV site are important, ensuring the correct administration parameters is essential to prevent immediate life-threatening cardiotoxicity.
✦ 台美臨床差異
美護規定 KCl 必須使用幫浦（IV Pump）；台灣亦全面推行幫浦給藥，但在護理評估層面上要求標準一致。