— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人被開立靜脈注射氯化鉀 20 mEq。護理師在給藥前必須優先執行下列哪項措施？
A client is prescribed intravenous potassium chloride 20 mEq. Which action must the nurse prioritize before administration?
- ACheck for the presence of a central venous catheter檢查是否有中心靜脈導管
- BEnsure the client has voided at least 30 mL/hr✓ 正解確保病人每小時排尿量至少 30 mL
- CVerify the concentration and infusion rate確認濃度與輸注速率
- DAssess the peripheral IV site for infiltration評估周邊靜脈穿刺處是否有滲漏
— Explanation · 中文詳解 —
給予氯化鉀前，護理師需確認腎功能是否正常。若無尿或尿量不足（<30 mL/hr），給予鉀離子極易導致嚴重高血鉀與致命性心律不整。雖然 C 選項（濃度與速率）也很重要，但腎臟排泄功能是安全給鉀的先決條件。C 為優先評估點，確保病人能排泄多餘鉀離子。
Ensuring adequate urine output is the priority because the kidneys are responsible for excreting excess potassium; administering potassium to a client with poor renal function can lead to life-threatening hyperkalemia. While verifying concentration and rate is important, confirming the client can safely eliminate the potassium is the fundamental safety prerequisite.
✦ 台美臨床差異
美台臨床對於給鉀前的尿量確認均為標準程序，惟美國護理師常需自行查核實驗室數據（如 BUN/Cr）。