# 將每組評估結果拖曳至周邊靜脈輸液治療最可能的併發症。

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395447&lang=zh-tw  
> language: zh-TW  
> subject: Parenteral/IV Therapies  
> category: PPT

## 題目

將每組評估結果拖曳至周邊靜脈輸液治療最可能的併發症。

**1.** 導管周圍蒼白涼感腫脹，伴輸注速度變慢

Select a category
Phlebitis
Infiltration
Fluid overload

**2.** 緊繃水腫的皮膚，且非起皰性液體從注射部位滲漏

Select a category
Phlebitis
Infiltration
Fluid overload

**3.** 沿靜脈走向出現溫熱、紅斑與壓痛

Select a category
Phlebitis
Infiltration
Fluid overload

**4.** 注射部位疼痛，可觸摸到靜脈索條

Select a category
Phlebitis
Infiltration
Fluid overload

**5.** 快速輸注期間出現新的呼吸困難、雙側囉音與血氧飽和度下降

Select a category
Phlebitis
Infiltration
Fluid overload

**6.** 頸靜脈怒張與體重快速增加，無新的局部注射部位異常

Select a category
Phlebitis
Infiltration
Fluid overload

## 解析

浸潤會在注射部位產生腫脹、涼感、蒼白或緊繃、滲漏及流速變慢。靜脈炎會產生溫熱、紅斑、壓痛，有時可觸摸到靜脈索條。體液過量為全身性，可能產生呼吸困難、囉音、血氧飽和度下降、頸靜脈怒張或體重快速增加。

## 深入解析

快速解答
注射部位涼且腫 = 浸潤；靜脈溫熱且壓痛 = 靜脈炎；呼吸與容積相關發現 = 體液過量。

為何此為正確
局部注射部位發現可區分浸潤與靜脈炎，而肺部或循環系統發現則表示全身性體液過量。起皰性藥物滲漏為外滲，需依藥物特定流程處理；本題將局部滲漏範例限定為非起皰性液體。

NCLEX決策規則
停止有疑慮的輸注並在嘗試沖洗前進行評估。首先保護個案，然後遵循機構政策進行導管移除、回抽、冷熱敷、抬高、向上通報與記錄。References
1NCBI Open RN: local complications of peripheral IV therapy
2NCBI Open RN: peripheral IV access

## 臨床情境

周邊靜脈輸液再評估
數名成人正在接受非起皰性靜脈輸液。護理師在停止輸注並遵循特定併發症機構流程之前，先比較注射部位與全身性發現。

## 重要概念

- **浸潤** — 非起皰性靜脈輸液意外滲漏至周圍組織。
- **靜脈炎** — 靜脈發炎，伴隨疼痛、溫熱、紅斑，有時可觸摸到索條。
- **體液過量** — 血管內容積過多，可能導致呼吸困難、囉音、氧合降低、頸靜脈怒張或體重快速增加。

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