— 降低風險 · MEDIUM · MCQ —
護理師準備為病人靜脈輸注氯化鉀 20 mEq。護理師的首要行動為何？
A nurse is preparing to administer potassium chloride 20 mEq IV piggyback to a client. What is the nurse's priority action?
- AEnsure the medication is diluted in 100 mL of fluid確保藥物稀釋於 100 mL 液體中
- BVerify the presence of a patent urine output✓ 正解確認有暢通之尿液排出
- CCheck the client's potassium level from yesterday檢查病人昨日的鉀離子濃度
- DObtain an EKG tracing取得心電圖描記
— Explanation · 中文詳解 —
給予鉀離子前，必須確認腎臟排泄功能正常，防止鉀離子過高導致心律不整。若無尿（<30 mL/hr），注射鉀離子會誘發致命的高血鉀。D、A、C 雖均為正確步驟，但確認腎臟功能是給予鉀離子的絕對前提（No pee, no P）。
The nurse's priority action is to verify adequate urine output because potassium is excreted by the kidneys, and administering it to a client with renal impairment can cause fatal hyperkalemia. While dilution, current lab values, and EKG monitoring are important safety steps, ensuring the client can excrete the potassium is the absolute prerequisite for safe administration.
✦ 台美臨床差異
美台對於鉀離子輸注規範趨於一致，均要求嚴格稀釋並監測尿量；台灣臨床常規亦會強烈要求先測量腎功能數值（BUN/Cr）。