— 藥理與非經腸給藥 · HARD · MCQ —
護理師準備對低血鉀病人輸注靜脈注射氯化鉀。下列哪項評估為最高優先？
A nurse is preparing to administer intravenous potassium chloride to a client with hypokalemia. Which assessment is the highest priority?
- AAssessing the client's current potassium serum level評估病人的當前血清鉀濃度
- BChecking the peripheral IV site for infiltration檢查周邊靜脈注射部位是否有滲出
- CConfirming the client's urine output is at least 30 mL/hr✓ 正解確認病人的尿液輸出量至少為30 mL/hr
- DMonitoring the client's heart rate監測病人的心率
— Explanation · 中文詳解 —
給予氯化鉀前，護理師必須確保病人腎功能正常，因鉀離子主要透過腎臟代謝。若尿量少於 30 mL/hr，表示可能存在腎衰竭，此時給予鉀離子極易導致致命性的高血鉀。其餘選項雖重要，但相較於腎功能評估以預防致命風險，均非首要安全檢查。
Potassium is excreted primarily through the kidneys, making adequate urine output a critical safety parameter before administration. Confirming urine output is at least 30 mL/hr ensures the client has sufficient renal function to eliminate excess potassium, thereby preventing life-threatening hyperkalemia.
✦ 台美臨床差異
美台皆嚴格執行給鉀前腎功能確認，但在美國，護理師可直接拒絕給藥並聯絡醫師，台灣護理師通常會先確認報告後與醫師討論。