— 藥理與非經腸給藥 · MEDIUM · MCQ —
一位病人正透過靜脈輸注氯化鉀（20 mEq in 100 mL NS）。護理師發現注射部位紅腫且溫熱。哪項措施是優先級最高的？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes the site is red, swollen, and warm to the touch. Which action is the priority?
- AApply a cold compress to the site在注射部位應用冷敷
- BFlush the IV line with normal saline以生理食鹽水沖洗靜脈導管
- CSlow the infusion rate減慢輸注速率
- DStop the infusion immediately✓ 正解立即停止輸注
— Explanation · 中文詳解 —
此臨床表現為靜脈炎或藥物滲漏。鉀離子具強刺激性，若發生滲漏或靜脈炎，首要步驟是立即停止輸注，以防止嚴重的組織壞死。後續再移除靜脈導管並根據單位規範評估是否需塗抹解毒劑或熱敷，但絕不能繼續輸注或嘗試沖洗。
Redness, swelling, and warmth at an IV site indicate infiltration or phlebitis; because potassium is highly irritating, the nurse must immediately stop the infusion to prevent severe tissue necrosis.
✦ 台美臨床差異
美國護理師常有權自行移除周邊 IV 並重新建立管路，台灣護理師執行時仍需依醫師醫囑或科室程序執行移除。