— 藥理與非經腸給藥 · HARD · MCQ —
病人正在靜脈輸注氯化鉀。護理師發現注射部位腫脹、觸感冰涼且發白。護理師的優先處置是什麼？
A client is receiving an intravenous infusion of potassium chloride. The nurse notices the site is swollen, cool to the touch, and blanched. What is the nurse's priority action?
- ASlow the infusion rate減緩輸注速率
- BAspirate the IV line for blood return抽吸靜脈導管確認血液回流
- CApply a warm compress施加溫熱敷
- DDiscontinue the infusion✓ 正解停止輸注
— Explanation · 中文詳解 —
上述症狀為「外滲（Infiltration）」。鉀離子屬於高風險藥物，若外滲會對周圍組織造成極大刺激甚至壞死。一旦發現應立即停止輸液，移除針頭，評估皮膚狀況。不可慢速滴注或抽回血，應儘速終止以減少組織傷害。
The symptoms indicate infiltration, where potassium chloride has leaked into surrounding tissues, posing a high risk for severe irritation and necrosis. The priority action is to immediately discontinue the infusion to stop further tissue damage, remove the catheter, and assess the site.
✦ 台美臨床差異
美台臨床對於化學性藥物外滲後的處置（冷/熱敷、拮抗劑）根據藥物性質有嚴謹的 Protocol，護理師需熟悉單位指引。