一位患有心臟衰竭病史的病人正在接受靜脈注射 Furosemide。下列哪項評估結果，護理師應優先通報醫療團隊？
A client with a history of heart failure is receiving intravenous furosemide. Which of the following assessment findings is most important for the nurse to report to the healthcare provider?
- ASerum potassium level of 3.2 mEq/L血清鉀濃度為 3.2 mEq/L正確答案
- BUrine output of 50 mL in the last hour最後一小時尿量為 50 mL
- CDaily weight reduction of 1 kg (2.2 lbs)每日體重減輕 1 kg (2.2 lbs)
- DBlood pressure 110/70 mmHg from 125/80 mmHg血壓由 125/80 mmHg 降至 110/70 mmHg
- A血清鉀濃度為 3.2 mEq/L
此題的核心概念在於利尿劑治療的電解質副作用監測。Furosemide 是一種強效的環利尿劑（loop diuretic），會抑制亨利氏環對鈉、鉀、氯的再吸收，因此極易導致低血鉀（Hypokalemia）。血鉀正常值為 3.5-5.0 mEq/L，病人目前為 3.2 mEq/L，屬於顯著異常。低血鉀會增加心律不整（如心室頻脈、心室顫動）的風險，特別是對於心衰竭病人，若合併使用毛地黃藥物，更易引發毒性反應。正確答案 A 是因為電解質失衡直接威脅心臟穩定性。選項 D 的血壓下降在預期內（脫水效果）；選項 C 的體重減輕代表利尿有效；選項 B 的尿量在正常範圍（>30 mL/hr），皆非首要通報事項。臨床推理上，護理師必須敏銳覺察電解質與心臟功能的連動關係，保障病人安全。
- A · 正確答案血清鉀濃度為 3.2 mEq/L
血鉀 3.2 mEq/L 低於正常值，低血鉀會引起心肌興奮性改變，導致致命性心律不整，是服用環利尿劑最危險的併發症，必須優先處理。
- B最後一小時尿量為 50 mL
每小時 50 mL 的尿量高於臨床公認的腎灌注最低標準（30 mL/hr），代表腎功能尚能維持，且利尿劑正在發揮作用。
- C每日體重減輕 1 kg (2.2 lbs)
一天減輕 1 公斤代表體內多餘的液體正被有效排出，這是心衰竭治療成功的指標，應持續觀察而非通報異常。
- D血壓由 125/80 mmHg 降至 110/70 mmHg
使用利尿劑後血壓從 125/80 降至 110/70 屬於預期內的治療反應（減少前負荷），只要病人沒有出現暈眩或休克徵象，不需優先通報。
在美國護理執業中，血鉀低於 3.5 通常會觸發醫院的「電解質補給協定」（Electrolyte Replacement Protocol），護理師可依 protocol 直接給藥後通報；在台灣，多數醫院仍維持傳統醫囑制，護理師需先獲得醫師書面或口頭醫囑後才能進行補鉀，但在急重症病房的臨床監測邏輯兩國一致。
English explanation
The core concept of this item is monitoring electrolyte adverse effects of diuretic therapy. Furosemide is a potent loop diuretic that inhibits sodium, potassium, and chloride reabsorption in the loop of Henle, easily causing hypokalemia. The normal serum potassium range is 3.5-5.0 mEq/L; the client's current level is 3.2 mEq/L, which is significantly abnormal. Hypokalemia increases the risk of dysrhythmias (such as ventricular tachycardia and ventricular fibrillation), especially in heart failure clients, and the risk of toxicity is even greater when combined with digoxin. Option A is correct because electrolyte imbalance directly threatens cardiac stability. The decreased blood pressure in option D is within the expected dehydration effect; the weight loss in option C indicates effective diuresis; the urine output in option B is within normal limits (>30 mL/hr), and none of these are the priority for reporting. Clinically, the nurse must be acutely aware of the relationship between electrolytes and cardiac function to protect client safety.
最近修訂：2026-10-05