— 藥理與非經腸給藥 · HARD · MCQ —
病人正接受靜脈輸注氯化鉀 20 mEq/100 mL，時間為 1 小時。哪項評估結果需要立即介入？
A client is receiving an intravenous infusion of potassium chloride 20 mEq/100 mL over 1 hour. Which assessment finding requires immediate intervention?
- AHeart rate of 88 bpm心率 88 次/分
- BUrine output of 40 mL/hr尿量 40 mL/小時
- CClient report of burning at the IV site✓ 正解病患主訴靜脈注射部位有灼熱感
- DMild redness at the infusion site輸注部位輕微發紅
— Explanation · 中文詳解 —
氯化鉀具有極強的刺激性。病人感到燒灼感通常是靜脈炎或藥物滲出的早期預兆。為了防止嚴重的組織壞死，護理師應立即停止輸注並評估血管通路。鉀離子過快輸注或滲漏至周邊組織會造成嚴重後果，必須優先處理以保護病人血管。
Potassium chloride is highly irritating to veins, and reports of burning at the infusion site indicate potential extravasation or phlebitis. This finding requires immediate intervention to stop the infusion and prevent severe tissue necrosis. While urine output and heart rate are important for monitoring potassium status, they do not indicate acute local vascular injury.
✦ 台美臨床差異
美台臨床皆嚴格要求鉀離子輸注需稀釋，且絕對禁止靜脈推注（IV Push）。