— 藥理與非經腸給藥 · HARD · MCQ —
病人正在靜脈輸注氯化鉀，下列哪項評估結果需要立即採取護理措施？
A client is receiving an intravenous infusion of potassium chloride. Which assessment finding requires immediate nursing intervention?
- ASerum potassium level of 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
- BUrine output of 40 mL per hour每小時尿量 40 mL
- CReport of burning at the IV insertion site✓ 正解靜脈穿刺部位有灼熱感
- DPresence of a palpable pulse in the extremity肢體可觸摸到脈搏
— Explanation · 中文詳解 —
氯化鉀具有高度刺激性，若輸注部位出現燒灼感，強烈暗示藥物可能滲漏至周邊組織（Infiltration）。若不及時停止輸注並移除導管，可能導致組織壞死或嚴重的蜂窩性組織炎。其他選項中，鉀離子數值正常，尿量達標且脈搏存在，均為安全輸注的正常生理指標。
Burning at the IV insertion site suggests potential infiltration of potassium chloride, which is highly irritating to tissues and can cause necrosis if not addressed immediately. The nurse must stop the infusion and assess the site promptly, whereas normal potassium levels, adequate urine output, and palpable pulses indicate safe administration.
✦ 台美臨床差異
在美國，KCl 注射液通常需經由中心靜脈導管或透過稀釋程序給予；台灣臨床若在周邊靜脈給予，護理師需高度警覺滲漏問題。