— 降低風險 · HARD · MCQ —
護理師為低血鉀病人輸注氯化鉀，下列何種評估結果需要立即處置？
A nurse is administering potassium chloride IV to a client with hypokalemia. Which assessment finding requires immediate intervention?
- ASerum potassium level is 3.8 mEq/L血清鉀濃度為 3.8 mEq/L
- BClient reports burning at the IV site✓ 正解個案報告靜脈注射部位有灼熱感
- CClient complains of mild nausea個案抱怨輕微噁心
- DUrine output is 40 mL/hr尿量為 40 mL/hr
— Explanation · 中文詳解 —
氯化鉀具有高度刺激性，若發生滲漏（Extravasation）會造成嚴重的組織壞死。病人若感到灼熱感，表示可能發生靜脈炎或滲漏，必須立即停止輸注並評估血管狀況，而非繼續觀察。其他選項如尿量正常、血鉀回升至正常範圍均屬預期療效。
Potassium chloride is highly irritating to veins, so immediate intervention is required if the client reports burning at the IV site, as this indicates potential extravasation or phlebitis. The infusion must be stopped immediately to prevent severe tissue necrosis. Normal urine output and serum potassium levels within range are expected findings and do not require urgent action.
✦ 台美臨床差異
美國護理師對高警訊藥物（High-alert meds）需獨立核對且嚴格執行滲漏監測；台灣對此類輸注的評估多由護理師執行，但標準化流程的教育訓練較少強調滲漏細節。