病人正在靜脈輸注氯化鉀（20 mEq/100 mL 生理食鹽水），護理師發現注射部位紅、熱、痛。優先採取的措施為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the IV site is red, warm, and painful. Which action is priority?
- AStop the infusion immediately✓ 正解立即停止輸注
- BSlow the infusion rate減慢輸注速率
- CFlush the IV line with normal saline以生理食鹽水沖洗靜脈管路
- DApply a cold compress冷敷
氯化鉀（KCl）屬於強刺激性藥物，若發生滲漏（Infiltration）或靜脈炎（Phlebitis），會對皮下組織造成嚴重化學性刺激，甚至導致組織壞死（Necrosis）。臨床上觀察到紅、熱、痛等跡象時，代表藥物可能已經滲出血管外。護理師的第一反應必須是立即停止輸注，以中斷藥物對周邊組織的進一步破壞。
Potassium chloride is a highly irritating solution that can cause severe chemical burns and tissue necrosis if it extravasates into surrounding tissues. Signs such as redness, warmth, and pain at the IV site indicate infiltration or phlebitis. The priority action is to immediately stop the infusion to prevent further tissue damage, rather than slowing the rate or flushing the line.
美國臨床對於高濃度鉀離子輸注的監測極為嚴格，通常建議使用中央靜脈導管（CVC）輸注高濃度 KCl 以降低周邊滲漏風險，且若發生滲漏，護理師需立即依據機構 protocol 採取包括移除導管及通知醫師等急救流程。