— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈滴注 20 mEq 氯化鉀。護理師發現靜脈注射處紅腫。護理師應優先採取什麼行動？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes redness and swelling at the IV site. Which action should the nurse take first?
- AStop the infusion immediately✓ 正解立即停止輸注
- BSlow the infusion rate減慢輸注速率
- CApply a warm compress to the site在注射部位應用熱敷
- DFlush the IV line with normal saline用生理食鹽水沖洗靜脈通路
— Explanation · 中文詳解 —
氯化鉀（Potassium chloride）屬於高警訊藥物（High-alert medication），具有強烈的組織刺激性。一旦發生滲漏（Extravasation），會導致嚴重的組織發炎、壞死甚至潰瘍。護理師發現注射處紅腫時，首要任務是立即中斷藥物輸注，以阻止更多藥物進入皮下組織，隨後再進行評估與處置，這是預防醫療傷害的關鍵步驟。
The nurse must stop the infusion immediately when signs of extravasation, such as redness and swelling, are noted to prevent further tissue damage from the vesicant potassium chloride. Continuing or slowing the infusion allows more harmful medication to enter the tissue, while flushing can exacerbate the injury.