病人正在靜脈輸注氯化鉀 20 mEq，溶於 100 mL 生理食鹽水。哪項評估發現需要立即介入？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. Which assessment finding requires immediate intervention?
- AThe infusion pump alarm sounds for a low battery輸注幫浦發出低電量警報
- BThe client complains of a burning sensation at the infusion site✓ 正解病患主訴輸注部位有灼熱感
- CSerum potassium level is 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
- DClient reports a mild headache病患報告輕微頭痛
氯化鉀具有強烈刺激性，若引起灼燒感，極大機率已發生滲漏（infiltration）或靜脈炎（phlebitis）。為防止組織壞死，必須立即停止輸注並移除點滴，評估部位。鉀離子不可透過周邊靜脈快速推注或直接滴入。其他選項中，鉀離子數值正常，電池低電量非臨床威脅，頭痛則需進一步評估但非立即致命威脅。
A burning sensation at the infusion site suggests infiltration or phlebitis, which is a critical concern when administering potassium chloride due to its tissue-irritating properties. Potassium can cause severe tissue necrosis if it leaks into surrounding tissues, so the infusion must be stopped immediately to prevent damage. Although the serum potassium level is normal, the local reaction poses an immediate physical threat requiring urgent intervention.
美國護理師對靜脈點滴渗漏的評估非常謹慎，因鉀離子外滲引起的法律糾紛較多；台灣護理師亦高度重視，處理流程相似。