— 藥理與非經腸給藥 · MEDIUM · SATA —
病人正在靜脈輸注氯化鉀。下列哪些評估發現應警覺可能有靜脈滲漏？（選所有適合的）
A client is receiving an intravenous infusion of potassium chloride. Which assessment findings should alert the nurse to potential infiltration? (Select all that apply.)
- ACoolness of the skin around the insertion site✓ 正解穿刺點周圍皮膚發涼
- BEdema at the site✓ 正解穿刺部位水腫
- CRedness and warmth along the vein沿著靜脈出現紅斑與發熱
- DLeaking of fluid at the insertion site✓ 正解穿刺點有液體滲漏
- EClient reports burning pain at the site✓ 正解病人報告穿刺部位有灼熱痛感
— Explanation · 中文詳解 —
滲漏（Infiltration）是指輸注液進入皮下組織，表現為局部腫脹、發涼、回血消失及輸液速度減慢。選項 C 為靜脈炎（Phlebitis）特徵，伴隨發紅與溫熱感，與滲漏不同。氯化鉀具強烈刺激性，滲漏會導致疼痛與組織損害。
Signs of IV infiltration include coolness, edema, leaking fluid, and burning pain at the insertion site. Potassium chloride is particularly irritating, so burning pain suggests the solution has leaked into surrounding tissues. Redness and warmth are indicators of phlebitis, not infiltration.
✦ 台美臨床差異
台美皆強調對高危險輸注液（如鉀）執行密集的部位監測，台灣護理規範對藥物滲漏的防護與補償機制有明確法律規範。