— 藥理與非經腸給藥 · HARD · MCQ —
病人正接受 20 mEq 氯化鉀加入 100 mL 生理食鹽水，於 1 小時內靜脈輸注。哪項評估結果需要立即介入？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline over 1 hour. Which assessment finding requires immediate intervention?
- ASerum potassium level of 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
- BPatient reports feeling thirsty病患表示感到口渴
- CReport of burning at the IV insertion site✓ 正解靜脈注射部位有灼熱感
- DHeart rate of 82 beats per minute心率為每分鐘 82 次
— Explanation · 中文詳解 —
氯化鉀具有強烈刺激性，若發生靜脈炎或滲漏會嚴重損害組織。病人主訴注射部位灼熱感是靜脈炎的早期徵象，護理師必須立即停止輸注並評估輸液部位。氯化鉀絕對不能經由周邊靜脈推注（IV Push），必須稀釋且嚴格控制滴速。
Potassium chloride is highly irritating to vein tissues, and burning at the IV site suggests phlebitis or infiltration, which requires immediate intervention to prevent tissue damage. The nurse should stop the infusion and assess the site promptly. Other findings such as normal serum potassium levels, thirst, or a normal heart rate do not indicate an immediate emergency related to the infusion.
✦ 台美臨床差異
美國常規單位多為 mEq，台灣亦同。臨床上美國護理師對高警訊藥物（如 KCl）的給藥確認程序極為嚴謹，台灣則常採雙人核對制以防錯。