— 生理適應 · MEDIUM · MCQ —
一位低血鉀病人，下列何種評估發現需要立即介入？
A nurse is caring for a client with hypokalemia. Which assessment finding requires immediate intervention?
- AFlattened T waves on ECG心電圖上T波平坦
- BMuscle weakness肌肉無力
- CShallow respirations✓ 正解呼吸淺促
- DConstipation便秘
— Explanation · 中文詳解 —
低血鉀影響肌肉收縮，特別是呼吸肌。呼吸淺快反映出橫膈膜肌肉無力，這是造成呼吸衰竭的前兆，危及生命，屬於 ABC (Airway, Breathing, Circulation) 中的 Breathing 問題，需優先處理。其餘症狀雖然重要，但不如呼吸穩定性急迫。
Hypokalemia affects muscle contraction, especially respiratory muscles. Shallow respirations reflect diaphragmatic weakness, a precursor to respiratory failure that is life-threatening and falls under the 'Breathing' component of ABC priorities. Other symptoms, though important, are less urgent than respiratory stability.
✦ 台美臨床差異
台美臨床對低血鉀的補鉀速度限制相似，皆嚴格禁止靜脈推注 (IV push) 以免心臟驟停。