— 藥理與非經腸給藥 · HARD · MCQ —
病人獲處方靜脈注射氯化鉀 40 mEq,需於 2 小時內輸注。開始給藥前優先評估為何?
A client is prescribed intravenous potassium chloride 40 mEq to be administered over 2 hours. What is the priority assessment before starting this infusion?
- APeripheral IV site integrity周邊靜脈注射部位完整性
- BSerum potassium level血清鉀濃度
- CUrine output✓ 正解尿液排出量
- DBlood pressure血壓
— Explanation · 中文詳解 —
給予氯化鉀前,確認腎功能(尿量)是預防高血鉀毒性的關鍵,因為鉀離子主要經由腎臟排泄。若無尿或少尿,輸注鉀離子可能導致急性高血鉀,引發致命性心律不整。其他選項雖為常規步驟,但尿量評估直接攸關病人安全,為給藥的前提條件。
Before administering intravenous potassium, the nurse must assess urine output to ensure adequate renal function for excretion. Since potassium is primarily eliminated by the kidneys, oliguria or anuria poses a significant risk for life-threatening hyperkalemia and cardiac arrhythmias.
✦ 台美臨床差異
台美臨床皆嚴格要求鉀離子輸注前的腎功能評估;美國護理師常依據自動化數據判讀,台灣則常仰賴檢驗報告單。