— 生理適應 · MEDIUM · MCQ —
護理師照護一位血鉀濃度 6.5 mEq/L 的病人，哪項評估結果需要立即通知醫師？
A nurse is caring for a client with a potassium level of 6.5 mEq/L. Which assessment finding requires immediate notification to the provider?
- AMuscle cramps in the lower extremities下肢肌肉痙攣
- BHyperactive bowel sounds腸鳴音亢進
- CPeak T-waves on the ECG✓ 正解心電圖上出現尖頂T波
- DIncreased urine output尿量增加
— Explanation · 中文詳解 —
高血鉀會影響心肌電生理，導致嚴重心律不整。心電圖出現尖頂 T 波（Peaked T-waves）是致命性心律不整（如室顫）的早期徵兆。B、A 雖是高血鉀症狀，但不如心臟問題緊急。D 是高血鉀可能原因（如腎功能受損）而非首要觀察指標。
Hyperkalemia affects myocardial electrophysiology and can lead to serious dysrhythmias. The appearance of peaked T waves on the ECG is an early sign of life-threatening dysrhythmia (such as ventricular fibrillation). Options B and A are also manifestations of hyperkalemia but are not as urgent as the cardiac findings. Option D may be a cause of hyperkalemia (such as impaired renal function) rather than the primary observation parameter.
✦ 台美臨床差異
美國護理師常需在發現 T 波變化後立即執行緊急降鉀處置（如給予鈣劑），台灣常需醫師確認後才能執行。