— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈輸注氯化鉀 20 mEq 溶於 100 mL 生理食鹽水。護理師觀察到輸注部位紅、腫、熱。優先採取的護理措施為何？
A client is receiving an intravenous infusion of Potassium Chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the site is red, warm, and swollen. What is the priority nursing action?
- AFlush the IV line with Normal Saline用生理食鹽水沖洗靜脈導管
- BStop the infusion immediately✓ 正解立即停止輸注
- CApply a warm compress局部熱敷
- DSlow the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
氯化鉀（Potassium Chloride）是一種高危險性藥物（High-alert medication），具有強烈的刺激性。當發生靜脈外滲（Extravasation）時，會造成周邊組織嚴重的化學性發炎，甚至導致壞死。因此，當觀察到輸注部位出現紅、腫、熱等外滲跡象時，優先行動必須是「立即停止輸注」（Stop infusion），以防止更多藥物進入皮下組織，隨後再進行移除導管與評估。
Potassium chloride is a high-alert medication that can cause severe tissue necrosis if it infiltrates. The priority action is to stop the infusion immediately to prevent further damage to the subcutaneous tissue.