— 生理適應 · MEDIUM · MCQ —
對於心電圖出現高聳 T 波的高血鉀病人，哪項護理措施最合適？
Which nursing intervention is most appropriate for a client with hyperkalemia exhibiting peaked T waves on the ECG?
- AAdminister potassium chloride orally口服給予氯化鉀
- BPerform passive range of motion exercises執行被動關節活動運動
- CPrepare to administer IV insulin and glucose✓ 正解準備給予靜脈注射胰島素和葡萄糖
- DEncourage intake of bananas and oranges鼓勵攝取香蕉和柳橙
— Explanation · 中文詳解 —
高血鉀（Hyperkalemia）在心電圖（ECG）上的典型表現為高聳 T 波（Peaked T waves）。這是心肌受高鉀影響的警訊，若不即時處理，會進展至 QRS 波變寬，最終導致心室顫動（VF）與心跳停止。治療核心是迅速將鉀離子移入細胞內，最有效的方法是靜脈輸注「胰島素與葡萄糖」。胰島素將鉀帶入細胞，葡萄糖則防止低血糖。
Hyperkalemia classically produces peaked T waves on ECG—a warning that without prompt treatment, QRS widening and ultimately ventricular fibrillation and cardiac arrest may occur. Core treatment is to shift potassium intracellularly; IV insulin with glucose is the most effective method. Insulin drives potassium into cells while glucose prevents hypoglycemia.