— 藥理與非經腸給藥 · MEDIUM · MCQ —
護理師監測靜脈點滴，發現注射部位水腫、發涼且無回血。優先動作為何？
A nurse is monitoring a client's IV site and observes edema, coolness, and lack of blood return. What is the nurse's priority action?
- AFlush the IV with saline以生理食鹽水沖洗靜脈通路
- BApply a warm compress施加熱敷
- CStop the infusion and remove the IV device✓ 正解停止輸注並移除靜脈留置針
- DSlow the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
觀察到水腫、發涼（Coolness）與無回血是典型的血管滲漏（Infiltration）症狀。優先動作是立刻停止給藥並移除導管，以防藥物進一步刺激組織。冷熱敷（B）視藥物性質而定，需先執行 A 才能保護安全。
Edema, coolness, and lack of blood return indicate IV infiltration, requiring immediate cessation of the infusion and removal of the catheter to prevent further tissue damage. Flushing the line or applying compresses before stopping the flow is unsafe and could exacerbate the injury.
✦ 台美臨床差異
台灣臨床若發現滲漏，通常會評估是否需改由遠端重新建立靜脈路徑。