護理師照護一位接受聚苯乙烯磺酸鈉（Kayexalate）治療高血鉀症的病人。治療期間護理師的優先評估為何？
A nurse is caring for a client with hyperkalemia who is prescribed sodium polystyrene sulfonate (Kayexalate). What is the nurse's priority assessment during treatment?
- ABlood pressure and heart rate.血壓與心率
- BMuscle strength and deep tendon reflexes.肌力與深層肌腱反射
- CUrine output and specific gravity.尿量與比重
- DBowel sounds and abdominal distension.✓ 正解腸鳴音與腹部膨脹
Kayexalate 是一種陽離子交換樹脂，主要在腸道中將鈉離子與鉀離子進行交換，隨糞便排出體外以降低血鉀。然而，此藥物最嚴重的副作用是腸壞死。護理師必須優先監測腸胃道狀態，包括腸鳴音、是否有便秘或腹脹（D）。如果病人沒有排便，藥物在腸道滯留過久，會增加腸穿孔的風險。雖然監測心跳（A）對於高血鉀很重要，但那是針對「疾病本身」，而題目問的是針對「Kayexalate 治療期間」的護理優先評估，應側重藥物安全性。尿量（C）與肌肉力量（B）雖重要，但腸道完整性是使用樹脂類藥物的特定關鍵風險。護理師應確保病人在治療期間腸道蠕動正常，必要時併用緩瀉劑。
Kayexalate is a cation-exchange resin that exchanges sodium for potassium in the intestine, with elimination via stool to lower serum potassium. Its most serious adverse effect is intestinal necrosis. The nurse must prioritize GI assessment—bowel sounds, constipation, or distention (D). Without bowel movements, prolonged drug retention increases the risk of perforation. While cardiac monitoring (A) is critical in hyperkalemia, the question concerns the drug-specific priority during Kayexalate therapy. Urine output (C) and muscle strength (B) are relevant but bowel integrity is the specific key risk with this resin. The nurse must ensure regular bowel movement during therapy and use laxatives as needed.
美國 FDA 曾發布關於 Kayexalate 導致腸壞死的黑框警告（Boxed Warning）；台灣臨床在使用此藥時，常更關注鉀離子下降的速度，對於腸道併發症的預防性評估需更被強調。