— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈輸注 20 mEq 氯化鉀於 100 mL 生理食鹽水中。護理師發現輸注部位腫脹、觸感冰冷且蒼白。護理師的首要行動為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the infusion site is swollen, cool to the touch, and pale. What is the nurse's priority action?
- ADiscontinue the infusion immediately✓ 正解立即停止輸注
- BApply a warm compress to the site在患處應用熱敷
- CSlow the infusion rate減慢輸注速率
- DAssess the client's potassium levels評估病人的鉀離子濃度
— Explanation · 中文詳解 —
此處呈現明顯的輸液滲漏（Infiltration）徵象，鉀離子對組織具刺激性，首要任務是立即停止輸注以防組織壞死。熱敷並非首選，應依據組織受損程度評估冷熱敷，且須先移除來源。抽血並非急迫處理滲漏之必要步驟，應先優先保護血管周圍組織安全。
The signs of swelling, coolness, and pallor indicate IV infiltration, where fluid leaks into surrounding tissue. Since potassium is a vesicant that can cause severe tissue damage and necrosis, the nurse's priority action is to immediately stop the infusion to prevent further harm.
✦ 台美臨床差異
美台臨床皆視滲漏為緊急事件，但美國護理師常有明確的各類藥物外滲 protocol 供執行。