— 降低風險 · MEDIUM · MCQ —
一位接受氯化鉀（KCl）靜脈輸注的病人，哪項評估發現需要立即處理？
Which assessment finding in a client receiving an IV infusion of potassium chloride requires immediate intervention?
- ASerum potassium level of 4.2 mEq/L血清鉀濃度為 4.2 mEq/L
- BUrine output of 40 mL/hour尿量為 40 mL/小時
- CPatient reports mild burning at the IV site病患報告靜脈注射部位有輕微灼熱感
- DPatient reports pain along the vein path✓ 正解病患報告沿靜脈路徑有疼痛感
— Explanation · 中文詳解 —
氯化鉀具有高度刺激性。若病人表示注射部位沿靜脈路徑感到疼痛，這通常是靜脈炎或滲漏的徵兆。若不立即停止輸注並評估，可能導致化學性靜脈炎甚至組織壞死。輕微灼熱感雖常見，但持續疼痛需優先處置；血鉀 4.2 及尿量 40mL/hr 皆屬安全範圍。
Pain along the vein path indicates potential phlebitis or extravasation, which requires immediate intervention because potassium chloride is highly irritating to vascular tissue. While mild burning may occur, persistent pain suggests tissue damage or infiltration that could lead to chemical phlebitis or necrosis if the infusion continues.
✦ 台美臨床差異
美國護理師對靜脈注射藥物外滲後的處置流程有嚴格的醫院規範，台灣則較常仰賴醫師判定。