— 藥理與非經腸給藥 · HARD · MCQ —
病人醫囑鉀離子 (KCl) 20 mEq 靜脈輸注，給藥前最重要的護理措施為何？
A client is prescribed intravenous potassium chloride (KCl) 20 mEq. What is the most important action for the nurse to perform before administration?
- AVerify the client's current serum potassium level✓ 正解確認病人當前的血清鉀濃度
- BEnsure the client has a patent peripheral IV site確保病人周邊靜脈通路暢通
- CAssess the rate of infusion using an electronic pump使用電子輸注泵評估輸注速率
- DDilute the KCl in at least 100 mL of fluid將氯化鉀稀釋於至少 100 mL 的液體中
— Explanation · 中文詳解 —
靜脈輸注鉀離子（KCl）具有高度風險，因其若給予過量或速度過快，極易引起高血鉀導致心跳停止。在執行給藥前，最重要的安全步驟是「確認血鉀數值」，確保病人確實有低血鉀且需要補充，以避免醫源性高血鉀。其他如稀釋與輸注泵則是給藥的技術性規範，但在臨床決策優先級上，確認給藥的必要性（即評估目前的電解質狀態）是第一要務。
Before administering intravenous potassium chloride, the nurse must verify the client's current serum potassium level to ensure the medication is clinically indicated. Administering potassium to a client with normal or elevated levels can lead to fatal cardiac arrhythmias, making this assessment the highest priority over technical preparation steps.