一位病人診斷為低血鉀,護理師應包含哪些照護措施?(選所有適合的)
A client is diagnosed with hypokalemia. Which interventions should the nurse include in the plan of care? (Select all that apply.)
- AMonitor for cardiac dysrhythmias✓ 正解監測心律不整
- BAdminister IV potassium chloride undiluted給予未稀釋的靜脈注射氯化鉀
- CEncourage intake of bananas, oranges, and potatoes✓ 正解鼓勵攝取香蕉、柳橙和馬鈴薯
- DAssess deep tendon reflexes✓ 正解評估深層肌腱反射
- EMonitor for muscle weakness and cramping✓ 正解監測肌肉無力與痙攣
低血鉀會影響神經肌肉及心肌功能。心臟監測可預防致命性心律不整(如 U 波)。富含鉀離子的飲食可協助改善輕度不足。肌肉無力與反射減弱是常見的神經肌肉徵象。選項 B 絕對錯誤,氯化鉀絕對不能直接注射,必須稀釋並經輸液幫浦給予,否則會導致心跳停止。
Hypokalemia affects neuromuscular and cardiac function. Cardiac monitoring can prevent lethal dysrhythmias (such as U waves). A diet rich in potassium can help correct mild deficiency. Muscle weakness and diminished reflexes are common neuromuscular signs. Option B is absolutely incorrect: potassium chloride must never be given by direct injection; it must be diluted and administered through an infusion pump, otherwise it will cause cardiac arrest.
美國醫院針對高濃度鉀補充有嚴格的雙人核對與輸液幫浦限制;台灣臨床亦嚴謹,但對於單位內護理師執行靜脈給藥的權限有較細緻的規範。