— 降低風險 · MEDIUM · MCQ —
護理師準備對低血鉀病人靜脈輸注氯化鉀，哪項評估是優先的？
A nurse is preparing to administer IV potassium chloride to a client with hypokalemia. Which assessment is priority?
- AEnsure the client has adequate urine output✓ 正解確保病人有足夠的尿量
- BAssess the IV site for signs of phlebitis評估靜脈穿刺處是否有靜脈炎的跡象
- CVerify the potassium concentration in the IV bag確認靜脈輸液袋中的鉀離子濃度
- DCheck the client's most recent serum creatinine level檢查病人最近的血清肌酸酐數值
— Explanation · 中文詳解 —
氯化鉀具有高毒性，若腎功能不佳導致尿量過少，輸注鉀離子極易引發高血鉀，嚴重時導致致命性心律不整。給藥前確認病人尿量足夠（通常為 >30 mL/hr），代表腎臟排泄功能尚可，是保障病人安全的首要關鍵評估。
Potassium chloride is highly toxic if administered too rapidly or to patients with renal impairment, potentially causing fatal arrhythmias. Ensuring adequate urine output is the priority assessment because it confirms that the kidneys can effectively excrete the excess potassium load. Without sufficient renal function, even standard doses can lead to dangerous hyperkalemia, making urine output a critical safety indicator before administration.
✦ 台美臨床差異
台美皆嚴格要求給藥前確認尿量，但在輸注泵（pump）的使用規範上，美國醫院多強制使用且需雙人核對。