— 降低風險 · EASY · MCQ —
護理師照顧一位有周邊靜脈點滴且傷口疼痛的病人。發現點滴部位發紅，且沿靜脈可摸到條索狀硬塊。護理師應採取哪項行動？
A nurse is caring for a client with a peripheral IV who reports pain at the site. The nurse notes redness and a palpable cord along the vein. Which action should the nurse take?
- ADiscontinue the IV and restart it in a different location✓ 正解拔除靜脈導管並在另一處重新建立
- BApply a cold compress immediately立即施加冷敷
- CFlush the IV with normal saline to check for patency以生理食鹽水沖洗靜脈導管以檢查通暢性
- DSlow the infusion rate減慢輸注速率
— Explanation · 中文詳解 —
發紅、疼痛且有條索狀硬塊是靜脈炎（Phlebitis）的典型特徵。首要處置是立即移除管路以防止進一步受損，並在另一處重新建立管路。調慢速度或沖洗管路無法解決發炎問題；針對靜脈炎，通常先採取溫敷而非冷敷（視臨床指引而定，但移除管路是第一步）。
Redness, pain, and a palpable cord are classic signs of phlebitis, indicating inflammation of the vein. The priority action is to discontinue the IV catheter immediately to prevent further tissue damage and restart access at a different site.
✦ 台美臨床差異
美國護理常使用 INS Phlebitis Scale (0-4) 進行評估；台灣臨床多使用類似的分級量表，處理原則均為立即拔除。