# 一位護理師接到電話醫囑，要為低血鉀個案靜脈推注 potassium chloride。哪項回應最為適當？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397302&lang=zh-tw  
> language: zh-TW  
> subject: Client Rights  
> category: MOC

## 題目

一位護理師接到電話醫囑，要為低血鉀個案靜脈推注 potassium chloride。哪項回應最為適當？

## 選項

1. 澄清並拒絕靜脈推注途徑，然後遵循指揮鏈。 **✔ 正確答案**
2. 請另一位護理師共同簽署電話醫囑。
3. 在給藥前將藥物稀釋於注射器中。
4. 緩慢給藥並監測心律。

**正確答案: 1**

## 解析

Potassium chloride 絕對不可靜脈推注，因為可能導致致命的心律不整。護理師必須質疑並拒絕不安全的醫囑，必要時使用指揮鏈。共同簽署、稀釋或緩慢給藥並不會使該途徑變得安全。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據及安全風險，選擇最符合「不安全的鉀醫囑」情境的回應。

記憶提示
將最強的線索群組與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的記憶。

## 臨床情境

臨床實務指引
對於「不安全的鉀醫囑」，將完整的線索模式與個案當前的穩定性、醫囑數據及預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，切勿僅根據單一線索選擇行動。

## 重要概念

- **指揮鏈** — 當安全疑慮未解決時所使用的通報途徑。
- **Potassium Chloride** — 一種需要稀釋和控制性靜脈給藥的電解質補充劑。
- **靜脈推注** — 對 potassium chloride 而言不安全的快速直接靜脈給藥方式。

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