— 降低風險 · HARD · MCQ —
護理師準備為病人靜脈輸注氯化鉀（KCl）20 mEq。給藥前最重要的護理措施是什麼？
A nurse is preparing to administer potassium chloride 20 mEq IV piggyback to a client. What is the priority nursing action before administration?
- AObtain a baseline blood pressure reading取得基線血壓讀數
- BVerify the patient's identity with two identifiers使用兩種識別方式驗證病人身分
- CCheck the client's most recent serum potassium level✓ 正解檢查病人最近的血清鉀濃度
- DEnsure the IV site is free of phlebitis確保靜脈穿刺部位無靜脈炎跡象
— Explanation · 中文詳解 —
氯化鉀（KCl）具有高度心臟毒性，給藥前確認病人的血鉀濃度（Serum potassium level）是 NCLEX 的鐵則。若病人已處於高血鉀（Hyperkalemia）狀態，再補充鉀離子可能引發致命性的心律不整（如心室顫動）。即使醫師已開立醫囑，護理師仍有責任在給藥前確認數值，確保藥物給予的安全性。
Potassium chloride carries a high risk of cardiac toxicity, making it essential to verify the client’s most recent serum potassium level before administration. Administering potassium to a client with normal or elevated levels can precipitate life-threatening arrhythmias, such as ventricular fibrillation.