— 降低風險 · EASY · MCQ —
護理師照護一位接受生理食鹽水輸液的病人，發現針扎處紅腫發熱。護理師應優先執行哪項措施？
A client is receiving an IV infusion of 0.9% Normal Saline. The nurse notes redness, swelling, and warmth at the IV site. Which action should the nurse perform first?
- ADiscontinue the intravenous infusion✓ 正解停止靜脈輸液
- BNotify the provider of the findings將發現通知醫師
- CSlow the rate of the infusion減慢輸液速率
- DApply a warm compress to the area在該部位施加熱敷
— Explanation · 中文詳解 —
本題測試靜脈炎（Phlebitis）的緊急護理處置。當靜脈注射部位出現紅、腫、熱等發炎徵象時，代表血管壁已受損，若持續輸液，不僅會加重發炎反應，甚至可能導致血栓性靜脈炎或藥物外滲（Infiltration）。護理師應遵循「移除刺激源」為第一優先原則（Safety），即立即終止輸液，隨後再進行評估與通報。
The presence of redness, swelling, and warmth indicates phlebitis, requiring immediate discontinuation of the IV infusion to remove the irritant and prevent further tissue damage. Notifying the provider and applying warm compresses are subsequent actions performed after the catheter has been removed.