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降低風險 · HARD · SATA

護理師正在為病人進行靜脈輸注氯化鉀。下列哪些情況發生時,護理師應立即停止輸注?(選所有適合的)

A nurse is caring for a client who is receiving intravenous potassium chloride. Which of the following findings indicate the nurse should stop the infusion? (Select all that apply.)

  • AThe infusion site shows redness and edema✓ 正解
    輸注部位呈現紅腫
  • BThe client reports a burning sensation at the IV site✓ 正解
    病人報告靜脈注射部位有灼熱感
  • CThe client's urine output is 40 mL/hr
    病人尿液排出量為每小時40毫升
  • DThe client experiences cardiac arrhythmias on the monitor✓ 正解
    監測器顯示病人出現心律不整
  • EThe client complains of moderate thirst
    病人抱怨中度口渴
Explanation · 中文詳解

氯化鉀具有強烈的組織刺激性。選項 A 與 B 為滲漏(Infiltration)跡象,極易導致組織壞死;選項 D 顯示高鉀血症已造成心律不整,嚴重威脅生命。C 選項的尿量正常,為給予鉀離子的安全指標;E 選項口渴並非鉀離子輸注的特殊不良反應。

Redness, edema, and burning sensations at the IV site indicate infiltration or phlebitis, which pose a high risk for tissue necrosis when infusing potassium chloride. Additionally, the development of cardiac arrhythmias suggests hyperkalemia, a potentially fatal complication requiring immediate cessation of the infusion. Adequate urine output confirms safe renal excretion, making it a positive indicator rather than a reason to stop.

✦ 台美臨床差異

美國常由護理師主導靜脈注射給藥判斷,台灣對於含鉀靜脈液體給予,護理師需確認醫囑濃度與輸注速率之嚴格限制。

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