— 降低風險 · HARD · SATA —
護理師準備靜脈注射氯化鉀。下列哪些護理措施是正確的？（選所有適合的）
A nurse is preparing to administer potassium chloride intravenously. Which of the following nursing actions are appropriate? (Select all that apply.)
- AEnsure the concentration does not exceed 10 mEq/100 mL for peripheral infusion✓ 正解確保周邊輸注的濃度不超過 10 mEq/100 mL
- BVerify the presence of adequate urine output before administration✓ 正解在給藥前確認有足夠的尿量
- CAdminister the medication via an infusion pump✓ 正解透過輸注幫浦給藥
- DAdminister the medication as an IV bolus to ensure immediate effect以靜脈推注方式給藥以確保立即效果
- EAssess the IV site for signs of phlebitis or infiltration✓ 正解評估靜脈注射部位是否有靜脈炎或滲漏跡象
— Explanation · 中文詳解 —
鉀離子靜脈注射嚴格禁止以推注（IV bolus）給予，以免造成心律不整導致心跳停止。給藥前需確保病人有足夠排尿量（腎功能正常），並使用輸液幫浦確保速率精確，鉀離子具強烈刺激性，必須監測注射部位。選項 D 為錯誤危險動作。
Appropriate actions include verifying adequate urine output to prevent hyperkalemia, using an infusion pump to control the rate, ensuring peripheral concentration does not exceed 10 mEq/100 mL to prevent vein damage, and assessing the IV site for phlebitis or infiltration due to potassium's irritant properties.
✦ 台美臨床差異
台美皆嚴禁鉀離子推注。美國護理師常需雙重核對，台灣醫院評鑑亦將其列為高警訊藥物之核心監測項目。