— 藥理與非經腸給藥 · MEDIUM · MCQ —
一位病人正在接受氯化鉀靜脈輸液，護理師發現靜脈注射部位紅腫且觸感冰涼。護理師應優先採取什麼行動？
A client is receiving an IV infusion of potassium chloride. The nurse notes the IV site is red, edematous, and cool to the touch. What is the priority nursing action?
- AFlush the line to check for patency沖洗管路以檢查通暢性
- BSlow the infusion rate減緩輸液速度
- CApply a warm compress to the area在該部位應用熱敷
- DStop the infusion and remove the catheter✓ 正解停止輸液並拔除導管
— Explanation · 中文詳解 —
出現紅腫與冰涼代表發生了輸液滲漏（Infiltration）。氯化鉀具有刺激性，若持續滲漏會導致嚴重組織損傷。護理師需立即停止輸液以防進一步擴散，移除導管並評估局部狀況。後續根據機構指引決定是否需熱敷或冷敷，但終止輸液是第一優先。
Redness, edema, and coolness at the IV site indicate infiltration, where fluid leaks into surrounding tissues. Since potassium chloride is highly irritating and can cause severe tissue damage, the priority action is to immediately stop the infusion and remove the catheter to prevent further harm.
✦ 台美臨床差異
台灣與美國在處理輸液外滲皆以移除管路為先，但針對鉀離子外滲後的處置流程，各醫院標準作業程序（SOP）可能因藥物濃度規定有所不同。