— 照護管理 · HARD · MCQ —
護理師照顧一位高血鉀病人。哪項措施應優先採取？
A nurse is caring for a client with hyperkalemia. Which priority action should the nurse take?
- AAdminister loop diuretics給予袢利尿劑
- BAssess deep tendon reflexes評估深層肌腱反射
- CMonitor hourly urine output監測每小時尿量
- DObtain an EKG✓ 正解取得心電圖
— Explanation · 中文詳解 —
高血鉀最致命的風險為心律不整（如心室顫動、心搏停止）。心電圖（EKG）可立即評估是否存在高血鉀引起的變化（如 T 波高尖、PR 間期延長），這是判斷緊急程度的首要步驟。利尿劑、測尿量、深層肌腱反射檢查皆為後續治療與評估，穩定心律為先。
The most lethal risk of hyperkalemia is cardiac arrhythmia (such as ventricular fibrillation or cardiac arrest). An EKG can immediately assess for hyperkalemia-induced changes (e.g., peaked T waves, prolonged PR interval) and is the first step in determining the urgency of intervention. Diuretics, urine output measurement, and deep tendon reflex testing are subsequent treatment and assessment steps; stabilizing cardiac rhythm comes first.
✦ 台美臨床差異
台美臨床對於高血鉀緊急處理流程一致，優先級皆為 EKG 評估。