— 降低風險 · MEDIUM · MCQ —
護理師準備執行氯化鉀 20 mEq 靜脈輸注。在開始輸注前，哪項評估最為重要？
A nurse is preparing to administer potassium chloride 20 mEq IV infusion. Which assessment is the most important to perform before starting the infusion?
- AAssess the peripheral IV site for redness評估周邊靜脈留置針部位是否有紅腫
- BMonitor the blood pressure監測血壓
- CReview the hourly urine output✓ 正解檢視每小時尿量
- DCheck the client's current serum sodium level檢查病人目前血清鈉濃度
— Explanation · 中文詳解 —
腎臟是排泄鉀離子的主要器官。給予鉀離子前，必須確認腎功能正常，臨床上最快的方式是評估尿量（至少 30 mL/hr）。若腎功能衰竭或無尿，給藥將導致高血鉀症，引發致命性的心律不整。其他選項雖為常規護理，但與鉀離子代謝安全性的關聯性次之。
The kidneys are the primary route for potassium excretion, so adequate renal function must be confirmed before administering IV potassium to prevent life-threatening hyperkalemia. The most critical assessment is reviewing hourly urine output, as a minimum of 30 mL/hr indicates sufficient kidney function to handle the potassium load safely.
✦ 台美臨床差異
鉀離子給藥在台美均有嚴格限制（不可 Push），且常規皆需確認尿量。