— 藥理與非經腸給藥 · EASY · MCQ —
病人正在靜脈輸注氯化鉀 20 mEq 溶於 100 mL 生理食鹽水。護理師發現注射部位發紅、溫熱且腫脹。護理師優先採取什麼行動？
A client is receiving an IV infusion of Potassium Chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the site is red, warm, and swollen. What is the nurse's priority action?
- AStop the infusion immediately✓ 正解立即停止輸注
- BApply a cold compress to the site在注射部位應用冰敷
- CSlow the infusion rate減慢輸注速度
- DFlush the IV line with normal saline用生理食鹽水沖洗靜脈導管
— Explanation · 中文詳解 —
此徵象顯示出現了靜脈炎或外滲（Infiltration）。由於氯化鉀具有強烈刺激性，若外滲到周邊組織會導致嚴重的組織損傷甚至壞死。首要步驟是立即停止輸注，避免更多藥物進入皮下組織，隨後再評估是否需要移除導管。
The signs of redness, warmth, and swelling indicate infiltration or phlebitis, which is particularly dangerous with potassium chloride due to its irritant properties that can cause severe tissue damage. The nurse’s priority action is to stop the infusion immediately to prevent further medication from entering the extravascular space.
✦ 台美臨床差異
美台臨床皆視外滲為優先移除點滴之指徵，但美國更強調後續藥物溢出處理的書面報告紀錄。