— 基本照護與舒適 · HARD · SATA —
病人表示靜脈注射部位出現嚴重疼痛，護理師評估後發現為靜脈滲漏（Infiltration）。應採取哪些措施？（選所有適合的）
A client complains of severe pain at a site of an IV infiltration. Which actions should the nurse perform? (Select all that apply.)
- AStop the infusion immediately✓ 正解立即停止輸液
- BApply a warm compress if indicated✓ 正解若適宜則施加溫敷
- CElevate the affected extremity✓ 正解抬高患肢
- DContinue the infusion at a slower rate以較慢速率繼續輸液
- EApply a cold compress to decrease swelling✓ 正解施加冷敷以減輕腫脹
— Explanation · 中文詳解 —
靜脈滲漏（Infiltration）是指輸液滲入周邊組織，導致腫脹、疼痛、發涼及蒼白。護理師首要行動是立即停止輸液以防更多藥物進入組織，接著評估是否需移除導管。抬高患肢利用重力促進靜脈回流，減輕組織水腫。關於冷敷或溫敷，必須視滲漏藥物的性質而定，一般而言冷敷可緩解疼痛，但若為血管收縮藥物，則需依照機構標準規範處理。
The nurse must immediately stop the infusion to prevent further tissue damage from the infiltrated fluid. The affected extremity should be elevated to promote venous return and reduce edema. Depending on the type of solution or medication infiltrated, applying warm or cold compresses may be indicated to manage pain and limit local spread, but continuing the infusion is never appropriate.