— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人獲醫囑給予靜脈注射氯化鉀 20 mEq。護理師在給藥前必須執行哪項措施？
A client is prescribed intravenous potassium chloride 20 mEq. Which action must the nurse perform before administration?
- AAdminister the medication via IV push over 5 minutes於 5 分鐘內經靜脈推注給藥
- BVerify that the client has a urinary output of at least 30 mL/hr✓ 正解確認病人每小時尿量至少達 30 mL
- CDilute the medication in at least 100 mL of fluid將藥物稀釋於至少 100 mL 液體中
- DCheck for the presence of a central venous catheter檢查是否存在中心靜脈導管
— Explanation · 中文詳解 —
鉀離子主要透過腎臟排泄，若病人無尿或少尿，給予鉀離子會導致嚴重高血鉀與致命性心律不整。給藥前確認腎功能與尿量是 NCLEX 重點安全考題。C 雖正確，但屬給藥過程細節；C 是嚴格禁止的給藥途徑；D 則視濃度而定，非絕對必要條件。
Before administering intravenous potassium, the nurse must verify adequate renal function by ensuring the client has a urinary output of at least 30 mL/hr to prevent hyperkalemia. Potassium chloride is strictly contraindicated for IV push administration due to the risk of fatal cardiac arrhythmias. While dilution is required, confirming urine output is the critical safety assessment prior to infusion.
✦ 台美臨床差異
美台臨床均視此為高警訊藥物（High-Alert Medication），但美國護理師常需透過電子病歷確認尿量記錄，台灣則多仰賴護理記錄或直接查詢尿袋量。