— 藥理與非經腸給藥 · HARD · MCQ —
病人獲醫囑給予靜脈輸注氯化鉀 20 mEq。給藥前最重要的護理措施為何？
A client is prescribed intravenous potassium chloride 20 mEq. Which nursing action is most critical prior to administration?
- ACheck the client's current serum potassium level檢查病人當前的血清鉀濃度
- BEnsure the IV site is free of infiltration確保靜脈注射部位無滲漏
- CVerify the concentration of the potassium solution確認氯化鉀溶液的濃度
- DAssess the client's hourly urine output✓ 正解評估病人的每小時尿量
— Explanation · 中文詳解 —
給予靜脈鉀離子前，確保腎功能正常至關重要。若尿量小於 30 mL/hr，表示腎臟排泄鉀離子能力不足，此時給藥極易導致致命的高血鉀與心律不整。雖然確認濃度與檢查血鉀也很重要，但排尿功能是排除鉀毒性的絕對安全指標。
Assessing the client's hourly urine output is the most critical action prior to administering intravenous potassium chloride to ensure adequate renal function for excretion. Inadequate urine output (less than 30 mL/hr) indicates a high risk for life-threatening hyperkalemia and cardiac arrhythmias. While checking serum levels and IV site integrity are important, confirming renal clearance is the primary safety gate.
✦ 台美臨床差異
台美均強調腎功能評估；美國醫院 protocol 多要求電子化記錄尿量，台灣臨床有時依賴護理紀錄紙或總量評估。