一位第四期慢性腎臟病 (CKD) 病人的血清鉀離子濃度為 6.8 mEq/L。護理師應優先執行哪項處置？

此題考查高血鉀症 (Hyperkalemia) 的緊急護理優先順序。當血鉀達到 6.8 mEq/L 時，這屬於醫療緊急狀況，因為高血鉀會直接干擾心肌細胞的去極化與再極化，導致致命的心律不整（如心室顫動、心搏停止）。根據優先護理原則，安全第一。在執行任何降低血鉀的治療（如給藥）之前，必須先建立生理監測。選項 B (放置心臟監測器) 能讓護理師即時發現 T 波尖聳 (peaked T waves)、PR 間期延長或 QRS 增寬等心電圖變化。選項 D (Kayexalate) 雖能降鉀，但起效慢（需數小時甚至數天），不適合緊急處置；選項 A 與當前危機無關；選項 C 是預防措施而非處置。在 NCLEX 思路中，當病人面臨潛在致命的心律不整時，「評估與監測」心臟狀態是行動的第一步，隨後則是準備給予葡萄糖酸鈣 (Calcium Gluconate) 以穩定心肌細胞膜。

This question tests the priority of emergency nursing care for hyperkalemia. When serum potassium reaches 6.8 mEq/L, this is a medical emergency, because hyperkalemia directly interferes with the depolarization and repolarization of cardiac muscle cells, leading to fatal arrhythmias (such as ventricular fibrillation or cardiac arrest). According to nursing priority principles, safety comes first. Before implementing any potassium-lowering treatment (such as medications), physiological monitoring must first be established. Option B (placing a cardiac monitor) allows the nurse to immediately detect ECG changes such as peaked T waves, prolonged PR interval, or widened QRS. Option D (Kayexalate) can lower potassium but acts slowly (hours to days) and is not suitable for emergency management; option A is unrelated to the current crisis; option C is a preventive measure rather than treatment. In NCLEX reasoning, when a patient faces a potentially fatal arrhythmia, 'assessing and monitoring' cardiac status is the first step in action, followed by preparing to administer calcium gluconate to stabilize the cardiac cell membrane.

在美國，這類病人常會在急診或 ICU 直接依 protocol 給予 'cocktail' 療法（胰島素加葡萄糖、鈣劑、重碳酸鈉）；台灣臨床上護理師需在監測心電圖的同時，迅速備妥上述藥物，並常需等待醫師確認後才進行靜脈推注。