— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正接受靜脈注射氯化鉀 20 mEq 於 100 mL 生理食鹽水中，護理師發現靜脈輸液部位紅腫且疼痛。請問優先處置為何？
A client is receiving an intravenous infusion of potassium chloride 20 mEq in 100 mL of 0.9% Normal Saline. The nurse notes redness, swelling, and pain at the IV insertion site. What is the priority nursing action?
- AApply a cold compress to the site在患處冷敷
- BNotify the healthcare provider通知醫療提供者
- CSlow the infusion rate減緩輸注速率
- DDiscontinue the infusion✓ 正解停止輸注
— Explanation · 中文詳解 —
此為典型的靜脈炎或外滲跡象。氯化鉀具有刺激性，一旦發生外滲需立即停止輸注以防組織壞死。不建議減慢速度，因為藥物仍會持續接觸受損血管。冰敷並非鉀離子外滲的標準處置。通知醫師雖重要，但優先保護組織完整性為護理責任。
Tertiary prevention focuses on managing established disease to prevent complications and disability, such as regular foot exams to prevent ulcers and annual retinopathy screenings to prevent blindness. Effective blood glucose management also serves as tertiary prevention by reducing the risk of nephropathy in clients with diabetes.
✦ 台美臨床差異
美國護理師依 protocol 可立即移除導管；台灣護理師執行程序相似，但需確認是否有靜脈炎分級並記錄於護理紀錄。