護理師為低血鉀病人靜脈輸注氯化鉀，檢查發現血鉀濃度升至 5.2 mEq/L。護理師的首要行動為何？
A nurse is administering a dose of IV potassium chloride to a client with hypokalemia. The nurse notes the client’s serum potassium level has increased to 5.2 mEq/L. What is the priority nursing action?
- ADiscontinue the infusion✓ 正解停止輸注
- BContinue the infusion as ordered依指示繼續輸注
- CAdminister furosemide to lower potassium給予呋塞米以降低鉀離子
- DNotify the laboratory to recheck the result通知實驗室重新檢測結果
高血鉀會引發致命性心律不整，當數值超過正常範圍（3.5-5.0 mEq/L）時，應立即停止鉀離子補充。5.2 mEq/L 已處於輕微高血鉀邊緣，持續輸注可能造成心臟毒性。此舉為保護病人安全的首要防禦措施，後續再回報醫師並評估心電圖變化。
Hyperkalemia can trigger life-threatening arrhythmias. When the serum potassium level exceeds the normal range (3.5-5.0 mEq/L), potassium supplementation should be stopped immediately. A level of 5.2 mEq/L is at the threshold of mild hyperkalemia, and continued infusion may cause cardiac toxicity. Stopping the infusion is the primary defensive measure to protect the client; the nurse can then notify the provider and evaluate for ECG changes.
美台臨床對於高血鉀處置原則一致，皆需先確保輸液管路移除再進行後續處置。