— 生理適應 · HARD · MCQ —
嚴重燒傷病人在前 24 小時內，護理師監測哪項發現最重要？
A client with severe burns is at high risk for electrolyte imbalances. Which assessment finding is most important for the nurse to monitor within the first 24 hours?
- AMetabolic alkalosis代謝性鹼中毒
- BHypernatremia高血鈉症
- CHypocalcemia低血鈣症
- DHyperkalemia✓ 正解高血鉀症
— Explanation · 中文詳解 —
燒傷早期（急性期）細胞損傷會釋放大量內細胞鉀離子進入血液，導致嚴重的「高血鉀」（Hyperkalemia），這可能引發致命性心律不整。鈉離子通常會因體液外滲而降低（低血鈉），而非高血鈉；酸鹼失衡則多表現為代謝性酸中毒。
In the early (acute) phase of burns, cellular injury releases large amounts of intracellular potassium into the blood, producing severe hyperkalemia, which can trigger life-threatening arrhythmias. Sodium levels typically fall due to fluid shifts (hyponatremia) rather than rising, and acid-base disturbances usually manifest as metabolic acidosis.
✦ 台美臨床差異
兩地燒傷病房對於急救期的電解質監控與輸液復甦指引相似。