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生理適應 · MEDIUM · SATA

護理師照護一名新診斷為低血鉀的病人,應採取哪些措施?(選所有適合的)

A nurse is caring for a client with a new diagnosis of hypokalemia. Which interventions should the nurse perform? (Select all that apply.)

  • AAdminister potassium chloride via IV push
    經靜脈推注給予氯化鉀
  • BMonitor heart rhythm using continuous telemetry✓ 正解
    使用連續心電圖監測心律
  • CAssess for muscle weakness and cramping✓ 正解
    評估是否有肌肉無力和抽筋
  • DEncourage intake of bananas, oranges, and potatoes✓ 正解
    鼓勵攝取香蕉、柳橙和馬鈴薯
  • EEnsure the client remains on bedrest during potassium infusion
    確保病人在輸注鉀離子期間保持臥床休息
Explanation · 中文詳解

低血鉀嚴重時會影響心肌電生理導致心律不整,因此連續心電圖監測是核心。此外,低鉀會引起骨骼肌無力與抽筋,需評估神經肌肉狀態。飲食補充如香蕉、柑橘等富含鉀離子食物為基本治療。A 項錯誤:嚴禁靜脈直接推注(IV Push)鉀離子,否則會導致心跳停止。E 項非絕對必要,但若有嚴重無力應預防跌倒。

Severe hypokalemia can affect myocardial electrophysiology and cause arrhythmias, so continuous ECG monitoring is core. In addition, low potassium causes skeletal muscle weakness and cramping, requiring neuromuscular status assessment. Dietary supplementation with potassium-rich foods such as bananas and oranges is a basic part of treatment. Option A is incorrect: IV push of potassium is strictly forbidden, as it can cause cardiac arrest. Option E is not absolutely required, but if the client has severe weakness, fall prevention should be initiated.

✦ 台美臨床差異

美國護理師常執行靜脈鉀離子濃度稀釋與滴注設定;台灣醫院多有明確規範,特別是高濃度補鉀需走中央靜脈。

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