護理師準備給予病人 20 mEq 氯化鉀靜脈點滴。下列哪項措施是必須採取的?
A nurse is preparing to administer potassium chloride 20 mEq IV piggyback to a client. Which action is essential for the nurse to take?
- AVerify that 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
- BUse a central line for all potassium administration使用中心靜脈導管進行所有鉀離子給藥
- CDilute the medication in at least 100 mL of fluid將藥物稀釋於至少 100 mL 的液體中
- DAdminister the medication via IV push over 2 minutes在 2 分鐘內經靜脈推注給藥
靜脈輸注氯化鉀(Potassium Chloride, KCl)具有極高的風險,因為鉀離子是導致心律不整的關鍵電解質。鉀離子主要經由腎臟排泄,若病人腎功能受損或尿量不足,給予鉀劑將導致高血鉀(Hyperkalemia),進而引發心室顫動(Ventricular Fibrillation)或心跳停止。因此,確認尿量是給藥前的安全守則。此外,KCl 具有強烈腐蝕性,必須充分稀釋並嚴格控制輸注速度,絕對禁止靜脈推注(IV Push)。
Verifying adequate urine output is essential before administering IV potassium because the kidneys are responsible for its excretion. Inadequate renal function or low urine output increases the risk of hyperkalemia, which can lead to life-threatening dysrhythmias such as ventricular fibrillation.
在美國臨床,KCl 的給藥規範極為嚴格,通常需透過輸液幫浦(IV pump)嚴格控制速率(一般不超過 10 mEq/hr),且若透過周邊靜脈給藥,濃度限制更嚴格。台灣臨床有時會見到較快速率的給藥,但在 NCLEX 考試中,請務必遵循「極度謹慎」的安全原則。