— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正接受靜脈輸注氯化鉀 20 mEq，護理師觀察到注射部位發紅與腫脹。首要護理措施為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes redness and swelling at the site. What is the priority nursing intervention?
- ASlow the rate of the infusion減慢輸注速度
- BStop the infusion immediately✓ 正解立即停止輸注
- CAssess the capillary refill distal to the site評估注射部位遠端的毛細血管再充盈時間
- DApply a warm compress to the area在該部位敷熱敷包
— Explanation · 中文詳解 —
氯化鉀具有強烈刺激性，若發生滲漏（Infiltration）或靜脈炎，必須立刻停止輸注以防組織壞死。此藥物對周邊血管極具刺激性，若已確認發生異常，持續輸注會造成嚴重併發症，優先處理步驟皆為中斷給藥，隨後才進行移除管路與評估。
Potassium chloride is highly irritating to peripheral veins and can cause tissue necrosis if it infiltrates. Upon noting redness and swelling at the infusion site, the nurse must immediately stop the infusion to prevent further damage. Subsequent actions include removing the catheter and assessing the site, but discontinuing the harmful agent is the priority.
✦ 台美臨床差異
美台皆嚴格執行高警訊藥物規範，但美國常見由護理師主導移除管路並記錄滲漏分級，台灣則強調通知醫師會診並進行後續敷料照護。