— 生理適應 · HARD · MCQ —
一位慢性腎臟病病人血鉀濃度為 6.2 mEq/L。護理師應優先執行哪項措施？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which intervention should the nurse prioritize?
- AObtain an ECG strip✓ 正解取得心電圖條帶
- BEncourage intake of low-potassium foods鼓勵攝取低鉀食物
- CAdminister oral Kayexalate口服給藥 Kayexalate
- DPrepare the client for dialysis為病人準備透析
— Explanation · 中文詳解 —
高血鉀可能導致致命的心律不整，優先評估心電圖（ECG）變化（如 T 波尖聳或 QRS 波變寬）以預防心跳停止。Kayexalate 與透析雖可降低鉀離子，但需時較久。飲食調整無法處理目前的危急高鉀。穩定心肌電位是第一優先。
Hyperkalemia can lead to fatal cardiac arrhythmias; therefore, priority must be given to evaluating ECG changes (such as peaked T waves or widened QRS) in order to prevent cardiac arrest. Although Kayexalate and dialysis can lower potassium, they take a longer time to act. Dietary modification cannot manage the current critical hyperkalemia. Stabilization of the myocardial electrical potential is the first priority.
✦ 台美臨床差異
美國護理師常依據急救 protocol 在醫囑前先執行心電圖；台灣通常先聯繫醫師開立緊急治療醫囑後才執行。