— 藥理與非經腸給藥 · EASY · MCQ —
病人獲醫囑給予 20 mEq 氯化鉀靜脈注射。護理師在給藥前優先採取哪項安全措施？
A client is prescribed intravenous potassium chloride 20 mEq. Which action by the nurse is the priority safety measure before administration?
- ACheck the infusion site for phlebitis檢查輸注部位是否有靜脈炎
- BReview the client's most recent serum glucose level檢視客戶最近的血清葡萄糖值
- CVerify the client's current urine output is adequate✓ 正解確認客戶目前的尿液排出量充足
- DDilute the medication in 50 mL of normal saline將藥物稀釋於 50 mL 生理鹽水中
— Explanation · 中文詳解 —
靜脈輸注鉀離子前，必須確保腎功能正常，因鉀離子主要透過腎臟代謝。若無尿或尿量過少，給予鉀離子極易導致高血鉀，誘發致命性心律不整。其他選項雖是給藥步驟，但確認排尿功能是決定能否給藥的關鍵門檻，避免鉀中毒。
Delegation to assistive personnel must adhere to the Five Rights of Delegation, assigning tasks appropriate for unlicensed staff such as assisting stable clients with ambulation. Assessment, care planning, medication administration, and teaching remain within the scope of practice for registered nurses. The nurse retains accountability for the delegation decision and ensures the task matches the personnel's competency.
✦ 台美臨床差異
台美皆嚴格執行鉀離子給藥審核；台灣對於鉀離子輸注常有獨立核對程序，美國則多依賴自動化調劑與護理師雙人核對。