— 降低風險 · HARD · MCQ —
護理師準備為病人靜脈輸注氯化鉀，下列哪項動作是確保安全的首要優先？
A nurse is preparing to administer intravenous potassium chloride to a client. Which action is the priority to ensure safety?
- AVerify the dose with a second nurse與第二位護理師核對劑量
- BCheck the client's urine output before administration✓ 正解給藥前檢查病人的尿液排出量
- CAdminister the drug at a rate of 10 mEq/hr via pump以幫浦以 10 mEq/hr 的速度給藥
- DAssess the IV site for signs of phlebitis評估靜脈注射部位是否有靜脈炎的跡象
— Explanation · 中文詳解 —
鉀離子透過腎臟排泄，若病人無尿或少尿，輸注鉀離子極易導致高血鉀危象。因此，確認腎功能與尿量是給予鉀離子前的絕對前提。其他選項（雙人核對、泵速控制、評估針位）均重要，但在臨床邏輯上，腎臟排泄功能是決定能否給藥的關鍵。
Since potassium is primarily excreted by the kidneys, checking urine output is the priority action to ensure the client has adequate renal function before administration. Without sufficient urine output, there is a high risk of developing life-threatening hyperkalemia. While other safety measures are important, confirming renal excretion capability is the fundamental prerequisite.
✦ 台美臨床差異
美國在給予高警訊藥物時，護理師需進行嚴格的 Independent Double Check，台灣較常仰賴電子系統提示。