— 藥理與非經腸給藥 · MEDIUM · MCQ —
病人正在靜脈輸注氯化鉀（20 mEq/100 mL 生理食鹽水），護理師發現輸液部位紅腫。護理師應優先採取什麼行動？
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 perform first?
- AStop the infusion immediately✓ 正解立即停止輸注
- BAdminister an antidote at the site在部位給予解毒劑
- CAssess the client's distal pulses評估病人的遠端脈搏
- DApply a cold compress to the site在部位敷冷敷
— Explanation · 中文詳解 —
氯化鉀（KCl）具有強烈刺激性（Vesicant），若發生靜脈滲漏（Infiltration）並持續輸注，會導致嚴重組織損傷甚至壞死。護理師發現滲漏徵兆（紅腫、疼痛）時，第一優先行動為「立即停止輸注（Stop the infusion）」，以阻止藥物進一步擴散至組織間隙，隨後再移除導管並進行相關護理評估。
Potassium chloride is a vesicant that can cause severe tissue damage if it extravasates; therefore, the nurse must stop the infusion immediately upon noticing redness and swelling. This action prevents further spread of the medication into the surrounding tissue before subsequent assessments or interventions are performed.