— 降低風險 · MEDIUM · MCQ —
護理師準備為低血鉀病人靜脈輸注氯化鉀，下列哪項是優先的安全性措施？
A nurse is preparing to administer intravenous potassium chloride to a client with hypokalemia. Which of the following is the priority safety action?
- AVerify the presence of a central venous access device確認是否有中心靜脈導管
- BEnsure the client has adequate urinary output✓ 正解確保病人有足夠的尿液排出量
- CDilute the medication in at least 100 mL of fluid將藥物稀釋於至少 100 mL 的液體中
- DAssess the infusion site for phlebitis評估輸注部位是否有靜脈炎
— Explanation · 中文詳解 —
靜脈輸注氯化鉀（KCl）具有高度風險，因為鉀離子是導致心律不整甚至心跳停止的關鍵電解質。在給藥前，護理師必須確認病人的腎臟功能正常，即尿液輸出量（Urinary output）至少需達到 0.5 mL/kg/hr，確保鉀離子能經由腎臟代謝排出，避免醫源性高血鉀。雖然稀釋與輸注部位同樣重要，但確認排泄功能是保障生命安全的最優先門檻。
Adequate urinary output is the priority safety check before administering IV potassium because the kidneys are responsible for excreting excess potassium. Ensuring urine output is at least 0.5 mL/kg/hr prevents life-threatening hyperkalemia and cardiac arrhythmias.