— 藥理與非經腸給藥 · EASY · MCQ —
病人正在靜脈輸注氯化鉀 20 mEq 溶於 100 mL 生理食鹽水。護理師發現注射部位紅腫發熱。護理師的首要行動為何？
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, warm, and swollen. What is the nurse's first action?
- AApply a cold compress to the site在注射部位施加冷敷
- BAssess for a pulse distal to the site評估注射部位遠端的脈搏
- 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 —
氯化鉀具有高度刺激性，若發生靜脈炎或外滲（extravasation），第一優先動作是立即停止輸注，以防組織壞死。後續應移除導管、回報並按機構規定處理。冷敷可能導致 KCl 外滲處血管收縮，應由醫生評估後處理，並非第一步驟。
Potassium chloride is a potent tissue irritant, and signs of redness, warmth, and swelling suggest infiltration or phlebitis. The nurse's first action is to stop the infusion immediately to prevent further tissue damage and potential necrosis before assessing the site or notifying the provider.
✦ 台美臨床差異
美台對於外滲處置類似，但在美國護理師常需自行依據 policy 決定是否給予特定解毒劑或熱敷，台灣多需先會診醫師。