— 生理適應 · HARD · MCQ —
慢性腎臟病病人血鉀值為 6.2 mEq/L。下列哪項評估發現需要立即處理？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which assessment finding requires immediate intervention?
- APeaked T waves on the ECG✓ 正解心電圖出現尖峰T波
- BNausea and vomiting噁心和嘔吐
- CIncreased urinary output尿液排出量增加
- DMuscle weakness肌肉無力
— Explanation · 中文詳解 —
高血鉀會影響心肌電生理，心電圖出現尖銳 T 波（Peaked T waves）是心律不整的前兆，極可能引發致命性心室顫動。其他選項雖為高血鉀症狀，但心電圖改變直接威脅生命，需優先處理（給予鈣劑保護心肌）。
Hyperkalemia disturbs myocardial electrophysiology; peaked T waves on the ECG are an early sign of dysrhythmia and may herald life-threatening ventricular fibrillation. Although the other options can also occur with hyperkalemia, ECG changes directly threaten life and must be addressed first (for example, by giving calcium to protect the myocardium).
✦ 台美臨床差異
美國護理師常依據 Protocol 直接啟動高血鉀緊急處置流程；台灣則多需由醫師評估後開立醫囑執行。