— 生理適應 · HARD · MCQ —
一位個案的血鉀濃度為 6.8 mEq/L，護理師優先採取的介入措施為何？
A client presents with a potassium level of 6.8 mEq/L. What is the priority nursing intervention?
- AAdminister sodium polystyrene sulfonate給予聚苯乙烯磺酸鈉
- BAdminister intravenous calcium gluconate給予靜脈注射葡萄糖酸鈣
- CAdminister insulin and glucose給予胰島素與葡萄糖
- DInitiate continuous cardiac monitoring✓ 正解開始連續心電圖監測
— Explanation · 中文詳解 —
高血鉀最致命的風險是心律不整及心跳停止。濃度高達 6.8 mEq/L 時，必須先將個案安置在心電圖監測下，以隨時觀察是否出現高 T 波、QRS 波變寬等心臟毒性變化。鈣劑、胰島素等藥物為後續的穩定細胞膜或促進鉀離子內移治療。
The most life-threatening risk of hyperkalemia is dysrhythmia and cardiac arrest. With a serum potassium as high as 6.8 mEq/L, the client must first be placed on continuous cardiac monitoring to observe for cardiotoxic changes such as peaked T waves and widened QRS complexes. Calcium, insulin, and other medications are subsequent treatments aimed at stabilizing the membrane or shifting potassium intracellularly.
✦ 台美臨床差異
美國在 ICU 環境下，高血鉀 protocol 極為嚴謹；台灣醫師對鉀離子數值的敏感度極高，通常會優先下醫囑給予藥物。