— 生理適應 · HARD · MCQ —
一位急性腎衰竭伴隨高血鉀的病人，哪項護理介入是必要的？
Which nursing intervention is essential for a client in acute renal failure experiencing hyperkalemia?
- AMonitor EKG for peaked T waves✓ 正解監測 EKG 是否有 T 波尖峰
- BEncourage a high-potassium diet鼓勵高鉀飲食
- CIncrease sodium intake增加鈉攝取
- DAdminister potassium-sparing diuretics給予保鉀利尿劑
— Explanation · 中文詳解 —
急性腎衰竭（Acute Renal Failure）導致排鉀功能喪失，極易引發高血鉀（Hyperkalemia）。高血鉀對心肌電生理具有毒性，會影響心室再極化過程，導致心電圖（EKG）出現高聳 T 波（Peaked T waves）、PR 間期延長或 QRS 波群變寬，最終可能引發致命性心律不整（如心室顫動），因此監測 EKG 是預防心跳停止的關鍵護理介入。
Acute renal failure causes loss of the ability to excrete potassium and readily produces hyperkalemia. Hyperkalemia is toxic to myocardial electrical activity, affecting ventricular repolarization and producing EKG changes such as peaked T waves, prolonged PR interval, or widened QRS complex, which may ultimately lead to fatal arrhythmias (e.g., ventricular fibrillation). Therefore, monitoring the EKG is a key nursing intervention for preventing cardiac arrest.