— 生理適應 · HARD · MCQ —
一位慢性腎臟病 (CKD) 個案血鉀濃度為 6.5 mEq/L。護理師應優先評估下列哪項數據？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L. Which finding should the nurse prioritize?
- AFrequency of bowel movements排便頻率
- BSkin turgor and moisture level皮膚彈性和濕潤程度
- CThe client's daily fluid intake病人的每日液體攝取量
- DElectrocardiogram (ECG) results✓ 正解心電圖 (ECG) 結果
— Explanation · 中文詳解 —
高血鉀可能導致致命性心律不整。血鉀 6.5 mEq/L 已達危險程度，護理師應立即檢查 ECG，尋找 T 波高尖（peaked T-waves）或 QRS 波變寬等徵象。C、B、A 雖與 CKD 管理相關，但並非針對致命性併發症的即時防護。
Hyperkalemia can cause life-threatening arrhythmias. A serum potassium of 6.5 mEq/L is dangerous, and the nurse should immediately obtain an ECG to look for peaked T-waves or QRS widening. Options C, B, and A are relevant to CKD management but do not address the immediate life-threatening complication.
✦ 台美臨床差異
台美臨床對於高血鉀的處理流程高度一致，皆以心電圖監測作為處理危險電解質的首選。