— 降低風險 · MEDIUM · MCQ —
護理師準備為低血鉀病人靜脈輸注氯化鉀。給藥前最優先的評估項目為何？
A nurse is preparing to administer potassium chloride IV to a client with hypokalemia. Which assessment is the priority before initiation?
- AVerify the presence of a patent urine output✓ 正解確認有暢通的尿液排出
- BCheck the client's current serum potassium level檢查病人當前的血清鉀濃度
- CAssess the IV site for signs of infiltration評估靜脈穿刺處是否有滲漏跡象
- DReview the client's most recent ECG rhythm strip檢視病人最近的心電圖波形
— Explanation · 中文詳解 —
鉀離子主要透過腎臟代謝，若病人無尿（anuria）或尿量不足，給予鉀離子會導致高血鉀危象（致命性心律不整）。雖然 B、D 也很重要，但安全給藥的前提是病人具備排泄能力。C 為給藥時的注意事項，非給藥前的首要生理指標。
Adequate urine output confirms that the kidneys can effectively excrete excess potassium, preventing life-threatening hyperkalemia. While serum levels and ECGs are important, ensuring renal function is the primary safety prerequisite before administering IV potassium.
✦ 台美臨床差異
台灣醫院通常會嚴格要求尿量紀錄後才給予靜脈輸注鉀離子。