— 藥理與非經腸給藥 · EASY · MCQ —
病人正接受氯化鉀靜脈輸注，自訴注射部位有灼熱感。護理師應採取的第一項措施為何？
A nurse is caring for a patient receiving an IV infusion of potassium chloride. The patient reports burning at the IV site. Which action should the nurse take first?
- ASlow the infusion rate減緩輸注速率
- BApply a cold compress to the site在注射部位應用冷敷
- CNotify the physician通知醫師
- DStop the infusion✓ 正解停止輸注
— Explanation · 中文詳解 —
氯化鉀屬於強刺激性藥物，若病人訴說灼熱感，極可能是發生外滲（Infiltration）或血管內膜炎。首要步驟是立即停止輸注，防止更多藥物滲入皮下組織，以免引起嚴重的組織壞死。後續再評估血管狀況及通知醫師是否更換給藥路徑。
The nurse must immediately stop the infusion because potassium chloride is a vesicant, and burning at the site suggests extravasation or phlebitis. Continuing the infusion risks severe tissue necrosis and damage. After stopping the infusion, the nurse should assess the site and notify the provider.
✦ 台美臨床差異
兩地標準均強調預防外滲，美國護理師常依政策自主拔除靜脈路徑，台灣護理師執行程序類似，但可能需醫師確認後方可進行後續處置。