護理師正在為病人靜脈注射氯化鉀。下列哪項觀察發現應立即回報醫師？
A nurse is administering a dose of intravenous potassium chloride to a client. Which observation should the nurse report to the provider immediately?
- AThe client reports a mild burning sensation at the IV site病人報告IV部位有輕微灼熱感
- BThe client's heart rate is 78 bpm and regular病人心跳為78 bpm且節律整齊
- CThe client's serum potassium level is 4.2 mEq/L病人血清鉀濃度為4.2 mEq/L
- DThe infusion site shows redness and edema✓ 正解輸注部位出現紅腫和水腫
靜脈注射氯化鉀（KCl）具有強烈的化學刺激性，若發生滲漏（Infiltration）或靜脈炎（Phlebitis），會導致嚴重的組織損傷甚至壞死。臨床評估中，紅腫與水腫是典型的滲漏徵象，必須立即採取「停止輸注、移除針頭、評估受損範圍、抬高肢體」等緊急護理措施。其他選項中，輕微灼熱感常見於高濃度 KCl 輸注，心跳穩定及血鉀正常則不構成立即停藥的理由。
Redness and edema at the infusion site indicate infiltration or phlebitis, which is critical because potassium chloride is highly irritating and can cause severe tissue damage or necrosis if it leaks into surrounding tissues. The nurse must immediately stop the infusion and notify the provider, whereas mild burning is a common expected side effect of concentrated potassium infusions.
美國醫院臨床對於高濃度鉀離子注射極為嚴謹，通常由中央靜脈導管（CVC）給予，若周邊靜脈給藥，必須使用輸液幫浦（Infusion pump）並嚴格監測部位。護理師在美國若發現滲漏，需立即根據機構政策進行評估，並可能需要會診 Wound Care Nurse。