— 降低風險 · HARD · MCQ —
護理師照護一位血鉀濃度為 6.5 mEq/L 的病人，哪項介入最優先？
A nurse is caring for a client with a potassium level of 6.5 mEq/L. Which is the priority intervention?
- APlace the client on a cardiac monitor✓ 正解將病人安置於心電圖監測儀上
- BMonitor vital signs監測生命徵象
- CCheck dietary intake檢查飲食攝取
- DAdminister potassium-wasting diuretics給予排鉀利尿劑
— Explanation · 中文詳解 —
高血鉀（6.5 mEq/L）具備致命性心律不整風險。心電圖監視器能即時偵測高血鉀引起的心臟傳導變化（如高 T 波、QRS 波變寬），這是救命的關鍵。監測生命徵象雖重要，但心律監控才能捕捉致命心律不整。藥物治療需待醫師開立，但先上監視器是護理師可立即執行的安全行動。
Hyperkalemia (6.5 mEq/L) carries a high risk of life-threatening dysrhythmia. Cardiac monitoring is essential to detect conduction changes (peaked T waves, widened QRS) in real time. While vital signs and dietary review have a role, only cardiac monitoring captures the imminent arrhythmia risk. Pharmacologic therapy requires provider orders, but applying a cardiac monitor is an immediate, nurse-initiated safety action.
✦ 台美臨床差異
美台臨床皆視高血鉀為「危險數值」（Critical Value），處理流程皆以心電圖監測為第一優先。