病人診斷為高血鉀症。護理師應預期執行哪項優先處置？
A client is diagnosed with hyperkalemia. Which priority intervention should the nurse anticipate?
- AEncourage sodium intake鼓勵攝取鈉
- BAdminister potassium chloride IV靜脈注射氯化鉀
- CAdminister IV insulin and glucose✓ 正解靜脈注射胰島素和葡萄糖
- DIncrease intake of high-potassium foods增加高鉀食物的攝取
高血鉀症（Hyperkalemia）極易引發嚴重的心律不整，甚至導致心跳停止。護理的首要任務是保護心肌，其次是降低血清鉀濃度。給予靜脈輸注胰島素（Regular insulin）與葡萄糖（Dextrose）是標準治療，透過胰島素將鉀離子帶入細胞內，並同時給予葡萄糖以預防低血糖。這屬於危急情況，必須迅速執行以穩定病人生命徵象。
Hyperkalemia can readily precipitate serious cardiac dysrhythmias and even cardiac arrest. The nurse's first priority is to protect the myocardium, followed by reducing the serum potassium level. Administering intravenous regular insulin with dextrose is the standard treatment: insulin drives potassium into the cells, while dextrose is given concurrently to prevent hypoglycemia. This is a critical situation requiring rapid intervention to stabilize the client's vital signs.
在美國臨床，當心電圖出現高尖 T 波（Peaked T waves）時，醫師會優先開立 Calcium gluconate（葡萄糖酸鈣）來穩定心肌細胞膜，隨後才給予胰島素與葡萄糖降鉀，此為 NCLEX 常考的優先順序。