— 生理適應 · MEDIUM · MCQ —
病人診斷為高血鉀。護理師應優先評估下列何種檢查結果以預防致命併發症？
A client is diagnosed with hyperkalemia. Which diagnostic finding should the nurse prioritize to prevent life-threatening complications?
- ASerum creatinine level血清肌酸酐濃度
- BSerum potassium level of 6.2 mEq/L血清鉀濃度為 6.2 mEq/L
- CPresence of muscle weakness出現肌肉無力
- DElectrocardiogram (ECG) tracing✓ 正解心電圖 (ECG) 描記
— Explanation · 中文詳解 —
高血鉀最致命的併發症為心律不整，因此透過心電圖（ECG）監測心律異常（如高尖 T 波、QRS 波變寬）是判斷病人是否面臨心跳停止風險的首要依據。雖然血鉀數據顯示數值，但心電圖直接反映了心肌電生理狀態的改變，是判斷嚴重程度的核心指標。
The most lethal complication of hyperkalemia is cardiac arrhythmia, so ECG monitoring (for changes such as peaked T waves and widened QRS) is the primary means of assessing whether the client is at risk for cardiac arrest. Although the serum potassium level shows the numeric value, the ECG directly reflects the electrophysiologic impact on the myocardium and is the key indicator of severity.
✦ 台美臨床差異
美國護理師常需在發現 ECG 異常時依 protocol 啟動緊急處置；台灣護理師通常先告知醫師，待醫囑給予鈣離子穩定心肌膜。