— 降低風險 · MEDIUM · MCQ —
護理師照護靜脈注射氯化鉀（KCl）的病人。下列何種評估結果暗示有潛在併發症？
A nurse is caring for a client who is receiving intravenous potassium chloride. Which assessment finding indicates a potential complication?
- ASlight nausea輕微噁心
- BHypotension低血壓
- CBurning at the infusion site✓ 正解注射部位有灼熱感
- DIncreased urine output尿量增加
— Explanation · 中文詳解 —
靜脈滴注氯化鉀具有強烈刺激性，注射部位出現灼燒感是靜脈炎或滲漏（extravasation）的早期徵兆。如果不立即處理，可能導致組織壞死。應立即暫停輸注並評估血管。噁心通常與補鉀速率相關，但灼燒感是更具立即威脅性的局部併發症。
Burning at the infusion site during intravenous potassium chloride administration signals phlebitis or extravasation, requiring immediate cessation of the infusion to prevent tissue damage. While nausea may occur, local irritation poses a more urgent risk of complications such as necrosis.
✦ 台美臨床差異
美國護理師對給藥給予權限較高，可自行決定暫停並更換部位；台灣護理師執行程序後通常需向醫師回報。