— 降低風險 · MEDIUM · MCQ —
一位慢性腎臟病病人血清鉀離子為 6.8 mEq/L。首要護理措施為何？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.8 mEq/L. What is the priority nursing action?
- AObtain an electrocardiogram (ECG)✓ 正解取得心電圖（ECG）
- BDocument the result in the medical record在病歷中記錄結果
- CAdminister sodium polystyrene sulfonate給予聚苯乙烯磺酸鈉
- DReview the client's dietary intake回顧病人的飲食攝取
— Explanation · 中文詳解 —
高血鉀（>6.5 mEq/L）是醫療急症，首要危險是引發致命性心律不整。護理師應優先執行 ECG 以評估心臟傳導受損情況（如 T 波尖聳）。B（降鉀藥物）重要但需在評估心臟後進行；C（飲食回顧）屬非急性期衛教；D 僅記錄是不夠的。
Hyperkalemia (>6.5 mEq/L) is a medical emergency, with the primary danger being life-threatening cardiac arrhythmias. The nurse should prioritize obtaining an ECG to evaluate cardiac conduction abnormalities (such as peaked T waves). Option C (a potassium-lowering medication) is important but should follow cardiac assessment; option D (dietary review) is non-acute teaching; and option B (documentation alone) is insufficient.
✦ 台美臨床差異
美國護理師多可根據高血鉀 Protocol 直接執行 ECG；台灣臨床多由醫師下達「加做 ECG」指令，但護理師應主動提醒並準備電極。