— 生理適應 · MEDIUM · MCQ —
一位病人被診斷為低血鉀，下列哪項護理評估最優先？
A client is diagnosed with hypokalemia. Which nursing assessment is priority?
- ACheck for muscle cramps檢查是否有肌肉痙攣
- BAuscultate heart sounds✓ 正解聽診心音
- CCheck bowel sounds檢查腸鳴音
- DAssess blood pressure評估血壓
— Explanation · 中文詳解 —
低血鉀嚴重影響心肌細胞的電位穩定，導致心律不整（如 QT 間期延長、U 波出現）。心臟功能的改變可能致命，因此心音聽診及心電圖監測是低血鉀病人的首要評估項目。其他如腸蠕動減緩、肌肉無力雖然重要，但皆不如心血管安全性迫切。
Hypokalemia significantly affects the electrical stability of myocardial cells, leading to dysrhythmias (such as prolonged QT interval and U-wave appearance). Changes in cardiac function may be life-threatening; therefore, cardiac auscultation and ECG monitoring are the priority assessments for the hypokalemic client. Although decreased bowel motility and muscle weakness are also important, none are as urgent as cardiovascular safety.
✦ 台美臨床差異
兩地均強調低血鉀病人必須使用心電圖監測，護理師需敏銳偵測心律變化。