護理師照護一位末期腎病(ESRD)病人。下列哪項檢驗結果需要最立即的干預?
A nurse is caring for a client with end-stage renal disease (ESRD). Which laboratory result requires the most immediate intervention?
- AHemoglobin 9.0 g/dL血紅素 9.0 g/dL
- BPotassium 6.8 mEq/L✓ 正解鉀 6.8 mEq/L
- CBUN 50 mg/dLBUN 50 mg/dL
- DCreatinine 6.5 mg/dL肌酸酐 6.5 mg/dL
末期腎病(End-Stage Renal Disease, ESRD)病人由於腎臟功能嚴重受損,無法有效排出體內的代謝廢物和電解質,因此常出現多種實驗室值異常。在眾多異常中,護理師必須判斷哪一個需要最立即的干預,這通常是基於對病人生命威脅的程度。核心概念是,高血鉀(hyperkalemia)是 ESRD 病人最危急的電解質失衡之一,因為它可能導致致命性的心律不整。因此,護理師的臨床思路應優先處理可能危及生命的電解質異常。
Severe hyperkalemia (potassium 6.8 mEq/L) poses the greatest immediate threat to an ESRD client due to the high risk of lethal cardiac arrhythmias. While anemia, elevated BUN, and creatinine are expected findings in end-stage renal disease, they do not require the same urgent intervention as critical electrolyte imbalances affecting heart rhythm.
美國護理強調依據數值危急程度自主決定優先順序;台灣通常會由系統自動警示危急值(Critical value)並通知醫師。