病人正在靜脈輸注 20 mEq 氯化鉀於 100 mL 生理食鹽水中，護理師觀察到輸注部位紅腫。護理師應先採取何項措施？
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 site. Which action should the nurse take first?
- AStop the infusion immediately✓ 正解立即停止輸注
- BFlush the IV line with 10 mL saline以 10 mL 生理食鹽水沖洗靜脈通路
- CApply a warm compress to the area在患處施加熱敷
- DNotify the healthcare provider通知醫療提供者
氯化鉀（KCl）屬於高警訊藥物，對血管壁具有強烈的刺激性。當輸注部位出現紅腫，代表可能已發生靜脈炎或藥物滲漏（Infiltration/Extravasation）。護理的首要原則是保護病人的組織安全，防止藥物繼續進入皮下組織造成壞死。臨床處置順序應為：立即停止輸注→拔除靜脈路徑→評估受損程度→根據機構指引決定是否需要熱敷或冷敷，並通知醫療團隊。
The nurse must immediately stop the infusion when redness and swelling occur, as these signs indicate infiltration or extravasation of potassium chloride, a highly irritating medication. Continuing the infusion could cause severe tissue damage, so discontinuing the source of injury takes priority over flushing, applying compresses, or notifying the provider.
在美國臨床，對於靜脈滲漏的處置非常嚴格且有標準流程（Protocol）。護理師通常會參考醫院的「Extravasation Management」指南，例如有些藥物需要冷敷，有些則需要特定解毒劑（如 Phentolamine），絕不可自行隨意熱敷。