— 照護管理 · HARD · MCQ —
一位病人的鉀離子濃度為 6.2 mEq/L。護理師應優先採取哪項措施？
A nurse is caring for a client with a potassium level of 6.2 mEq/L. Which action should the nurse prioritize?
- ANotify the physician and prepare for potential ECG monitoring✓ 正解通知醫師並準備潛在的心電圖監測
- BProvide a banana for potassium intake提供香蕉供鉀離子攝取
- CEncourage the client to drink more water鼓勵病人多喝水
- DDocument the lab result and continue with normal care記錄檢驗結果並繼續常規照護
— Explanation · 中文詳解 —
高血鉀症（大於 5.0 mEq/L）可能導致致命性的心律不整。6.2 mEq/L 為嚴重的危急值，必須立即通知醫師並準備監測心電圖，以防心室顫動或停搏。香蕉含鉀，絕對禁止；多喝水無法改善嚴重高血鉀，應採取醫療介入。
Hyperkalemia (potassium greater than 5.0 mEq/L) can lead to lethal cardiac arrhythmias. A potassium of 6.2 mEq/L is a critical value, and the nurse must immediately notify the physician and prepare for ECG monitoring to prevent ventricular fibrillation or cardiac arrest. Bananas are high in potassium and are strictly contraindicated; increasing fluid intake cannot correct severe hyperkalemia, and medical intervention is required.
✦ 台美臨床差異
台美皆將危急值（Critical Value）列為醫療安全指標，必須即時通報。