— 生理適應 · HARD · MCQ —
護理師準備靜脈輸注氯化鉀（KCl）。下列何者為最重要的護理安全考量？
A nurse is preparing to administer potassium chloride (KCl) IV. Which of the following is the most important nursing safety consideration?
- AMonitor for signs of hyperkalemia during infusion監測輸注期間高血鉀徵象
- BEnsure the client has adequate urine output✓ 正解確保病人有足夠的尿量
- CVerify the concentration is no greater than 10 mEq/100 mL確認濃度不超過10 mEq/100 mL
- DAdminister the infusion via a central line only僅透過中心靜脈導管進行輸注
— Explanation · 中文詳解 —
氯化鉀（KCl）是高警訊藥物（High-alert medication）。給藥前最關鍵的護理安全考量是確認腎功能是否足夠，因為鉀離子主要透過腎臟代謝，若無足夠尿量（通常指 >30 mL/hr），注入的鉀離子將無法排出，導致嚴重的致命性高血鉀（Hyperkalemia），進而引發心律不整甚至心跳停止。臨床上，無論濃度多少或給藥途徑為何，若無尿，絕對嚴禁給予鉀離子。
Potassium chloride is a high-alert medication primarily excreted by the kidneys; therefore, verifying adequate urine output is the most critical safety step to prevent life-threatening hyperkalemia. Without sufficient renal function, potassium cannot be eliminated, leading to potentially fatal cardiac arrhythmias regardless of infusion rate or concentration.