— 生理適應 · EASY · MCQ —
病人診斷為高血鉀。護理計畫中優先應包含哪項護理介入？
A client is diagnosed with hyperkalemia. Which priority nursing intervention should be included in the plan of care?
- AAdminister potassium-sparing diuretics給予保鉀利尿劑
- BRestrict physical activity限制身體活動
- CEncourage intake of bananas and oranges鼓勵攝取香蕉和柳橙
- DPlace the client on a cardiac monitor✓ 正解將病人連接至心電圖監測器
— Explanation · 中文詳解 —
高血鉀（Hyperkalemia）對心肌傳導系統具有致命影響，可能導致心律不整（如 T 波高尖、QRS 波變寬，甚至心室顫動或心搏停止）。因此，對於高血鉀病人，優先的護理介入是建立心電圖監測（cardiac monitoring），以便即時偵測心臟電生理的變化，並在必要時採取緊急處置。藥物治療需在監測下進行。
Hyperkalemia has life-threatening effects on cardiac conduction, including peaked T waves, widened QRS, ventricular fibrillation, and cardiac arrest. The priority intervention is cardiac monitoring so that life-threatening dysrhythmias can be detected and treated immediately. Pharmacologic therapy follows under monitoring.