一位末期腎病（ESRD）病人漏掉了兩次血液透析。病人的血鉀值為 6.8 mEq/L。護理師應優先執行哪項醫囑以保護病人免於致命性併發症？
A client with end-stage renal disease (ESRD) missed two hemodialysis sessions. The client's potassium level is 6.8 mEq/L. Which medication order should the nurse implement first to protect the client from life-threatening complications?
- ARegular insulin 10 units with 50% Dextrose IV普通胰島素 10 單位搭配 50% 葡萄糖靜脈注射
- B10% Calcium gluconate 10 mL IV over 5 minutes✓ 正解10% 葡萄糖酸鈣 10 mL 於 5 分鐘內靜脈注射
- CFurosemide 40 mg intravenous pushFurosemide 40 mg 靜脈推注
- DSodium polystyrene sulfonate 30 g orallySodium polystyrene sulfonate 30 g 口服
高血鉀（Hyperkalemia）最危險的併發症是致命性心律不整（如心室顫動）。當血鉀高達 6.8 mEq/L 時，心肌細胞的靜止膜電位改變，極易發生停搏。藥物處置有三部曲：1. 穩定心肌（Stabilize）：給予鈣劑（Calcium gluconate），它不降低血鉀，但能提高心肌去極化閾值，防止心律不整，這是最優先的。2. 轉移血鉀（Shift）：給予胰島素加葡萄糖（A），使鉀離子進入細胞內。3. 排除鉀離子（Remove）：透過腸道（D）、利尿劑（C）或透析排除。對於 ESRD 病人，利尿劑（C）通常無效；腸道排鉀（D）起效太慢（需數小時）。因此，在等待透析或鉀離子轉移前，必須先用鈣劑護心，這符合 NCLEX 的安全優先原則。
The most dangerous complication of hyperkalemia is a lethal arrhythmia (such as ventricular fibrillation). When serum potassium reaches 6.8 mEq/L, the resting membrane potential of myocardial cells is altered, making cardiac arrest extremely likely. Pharmacologic management follows three steps: 1. Stabilize the myocardium: administer calcium gluconate, which does not lower the potassium level but raises the depolarization threshold of myocardial cells to prevent arrhythmia; this is the highest priority. 2. Shift potassium intracellularly: administer insulin with glucose (A) to drive potassium into cells. 3. Remove potassium: through the intestines (D), diuretics (C), or dialysis. In patients with ESRD, diuretics (C) are usually ineffective, and intestinal removal (D) acts too slowly (requiring several hours). Therefore, while waiting for dialysis or potassium shifting, calcium must first be given to protect the heart, which is consistent with the NCLEX safety-first principle.
美國 NCLEX 考試極度強調『Stabilize before Shifting』的邏輯。台灣臨床流程中，醫師通常會同時開立鈣劑與胰島素，護理師在執行時需有『先推鈣』的意識。此外，美國已較少使用 Kayexalate（因腸壞死風險），而台灣臨床仍有一定比例的使用。