— 照護管理 · MEDIUM · MCQ —
護理師接到檢驗室電話，顯示病人的鉀離子濃度為 2.8 mEq/L，護理師的第一個動作為何？
A nurse receives a phone call from the laboratory reporting a critical potassium level of 2.8 mEq/L for a client. What is the nurse's first action?
- AAssess the client for cardiac arrhythmias✓ 正解評估病人是否有心律不整
- BNotify the physician immediately立即通知醫師
- CDocument the result in the electronic medical record將結果記錄於電子病歷
- DPrepare to administer oral potassium supplementation準備給予口服鉀離子補充劑
— Explanation · 中文詳解 —
接到危急值（Critical Value）報告時，首要步驟是評估病人的生理狀況。鉀離子過低（低血鉀）會影響心肌電生理，導致嚴重心律不整。護理師應先確認病人目前的生命跡象與心電圖變化，再通知醫師並執行後續醫囑，以確保病人當下安全。
When receiving a critical value report, the first step is to assess the patient's physiological status. Severe hypokalemia affects myocardial electrophysiology and can lead to serious arrhythmias. The nurse should first confirm the patient's current vital signs and ECG changes, then notify the physician and follow subsequent orders, ensuring the patient's immediate safety.
✦ 台美臨床差異
美台對於危急值的通報規範（Critical Result Protocol）一致，皆強調即時通報與執行後續醫囑之重要性。