— 降低風險 · MEDIUM · MCQ —
護理師照護一位接受靜脈點滴輸注氯化鉀的病人，發現輸注部位腫脹、冰冷且蒼白。護理師應優先採取何種措施？
A nurse is caring for a client receiving an IV infusion of potassium chloride. The nurse notices the infusion site is swollen, cool, and pale. Which action should the nurse take first?
- AApply a warm compress應用溫敷
- BSlow the infusion rate減慢輸注速度
- CStop the infusion immediately✓ 正解立即停止輸注
- DElevate the affected extremity抬高患肢
— Explanation · 中文詳解 —
輸注部位出現腫脹、蒼白、冰冷，顯示已發生靜脈滲漏（Infiltration）。氯化鉀具刺激性，若外滲至皮下組織恐造成組織壞死。首要步驟必須立即停止給藥，以防更多藥物進入組織間隙，之後再移除導管並評估局部狀況。
Swelling, coolness, and pallor at the IV site are classic signs of infiltration, where fluid leaks into surrounding tissue. Because potassium chloride is highly irritating and can cause tissue necrosis, the nurse must stop the infusion immediately to prevent further damage before assessing the site or notifying the provider.
✦ 台美臨床差異
美台處理滲漏原則一致，但美國護理師常有明確的「滲漏護理」 protocol 決定是否需給予解毒劑。