— 生理適應 · MEDIUM · SATA —
下列哪些關於低血鉀病人的評估發現需要護理師立即關注？（選所有適合的）
Which assessment findings in a client with hypokalemia require immediate attention by the nurse? (Select all that apply.)
- APresence of U waves on the ECG✓ 正解心電圖出現 U 波
- BPatient report of muscle weakness病人主訴肌肉無力
- CDecreased bowel sounds腸鳴音減弱
- DRespiratory rate of 10 breaths/min✓ 正解呼吸頻率 10 次/分
- ESerum potassium level of 2.8 mEq/L✓ 正解血清鉀離子濃度 2.8 mEq/L
— Explanation · 中文詳解 —
低血鉀嚴重時，心電圖會出現 U 波，且因呼吸肌無力導致呼吸抑制（RR 10 次/分），血鉀 2.8 mEq/L 已屬嚴重低血鉀範圍。肌肉無力與腸蠕動減慢雖為低血鉀症狀，但相較於心肺功能受損，屬於次要緊急關注事項。
In severe hypokalemia, the ECG shows U waves, and weakness of the respiratory muscles can cause respiratory depression (RR of 10/min); a serum potassium of 2.8 mEq/L falls within the severe hypokalemia range. Muscle weakness and decreased bowel motility are also symptoms of hypokalemia, but compared with cardiopulmonary compromise they represent secondary concerns.
✦ 台美臨床差異
美國護理師依 protocol 給予 IV 鉀補充，台灣多嚴格要求醫囑開立後才給予，執行程序上較嚴謹。