護理師照護接受靜脈化療的病人時，發現注射部位紅腫且觸感冰冷，應優先採取何種措施？
A nurse is caring for a client who is receiving intravenous chemotherapy. The nurse notes the site is red, swollen, and cool to the touch. Which action should the nurse take first?
- ADiscontinue the intravenous infusion immediately✓ 正解立即停止靜脈輸注
- BNotify the provider and request an antidote通知醫師並請求解毒劑
- CApply a warm compress to the site在注射部位敷溫熱敷布
- DAspirate for blood return to check for placement抽吸以確認是否有血液回流，以檢查導管位置
本題測試化療藥物外滲（extravasation）的緊急處置。化療藥物多具備組織發泡性（vesicant），一旦滲漏至血管外，會造成嚴重的組織壞死甚至永久性損傷。發現紅腫、冰冷等跡象時，護理師應立即停止輸液（Stop the infusion）以阻止更多藥物進入受損部位。這是所有護理介入中的最高優先級，隨後才進行評估或通知醫師進行解毒處理。
The nurse must immediately discontinue the intravenous infusion upon signs of extravasation, such as redness, swelling, and coolness, to prevent further tissue damage from vesicant chemotherapy agents. Stopping the infusion is the highest priority before notifying the provider or applying specific treatments.
美國臨床對於化療外滲有嚴格的護理守則（Protocol），通常會要求保留靜脈導管以利於醫師進行解毒劑（如 hyaluronidase）的局部注射，若立即拔除導管可能造成解毒劑無法精確給予。