— 降低風險 · MEDIUM · MCQ —
病人醫囑開立經由周邊靜脈輸注 20 mEq 氯化鉀。護理師的優先處置為何？
A client is prescribed intravenous potassium chloride 20 mEq via peripheral line. What is the nurse's priority action?
- ARequest the physician to insert a central line before infusion要求醫師在輸注前插入中心靜脈導管
- BVerify the concentration and dilution of the potassium solution✓ 正解確認鉀溶液濃度與稀釋比例
- CAssess the apical pulse rate for one full minute完整測量一分鐘的心尖脈率
- DAdminister the medication as an IV push經靜脈推注給藥
— Explanation · 中文詳解 —
鉀離子具有強烈刺激性，若濃度過高會造成血管炎與組織壞死。護理師給藥前務必確認輸注濃度與稀釋液體，嚴禁直接靜脈推注（IV push）。周邊靜脈輸注鉀離子通常要求濃度不高於 10 mEq/100mL 且流速需控制。
Potassium chloride is highly irritating to vascular tissue and can cause severe phlebitis or tissue necrosis if infused undiluted. The nurse must verify that the solution is properly diluted and administered at a safe rate to prevent local tissue damage during peripheral infusion.
✦ 台美臨床差異
台美皆嚴格禁止 KCl 推注，但台灣對給藥查核（三讀五對）的流程紀錄要求更為繁瑣。