一位慢性腎臟病病人血鉀濃度為 6.5 mEq/L。護理師應優先執行哪項措施？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L. Which intervention should the nurse prioritize?
- AObtain an ECG✓ 正解取得心電圖
- BPrepare the client for emergent hemodialysis為病人準備緊急血液透析
- CAdminister oral sodium polystyrene sulfonate口服給予聚苯乙烯磺酸鈉
- DEncourage intake of clear fluids鼓勵攝取清流質
高血鉀最致命的併發症為心律不整及心跳停止。心電圖可監測有無 T 波高聳（Peaked T waves）或 QRS 波變寬等危險徵兆，護理師需先評估心律穩定性，再依醫囑給予降鉀治療。C 與 B 雖然是處理高血鉀的手段，但在緊急狀態下評估心電圖是優先的護理評估。
The most lethal complications of hyperkalemia are cardiac dysrhythmias and cardiac arrest. The ECG can be used to monitor for dangerous changes such as peaked T waves or widening of the QRS complex; the nurse must first assess cardiac stability before administering potassium-lowering therapy as ordered. Although options C and B are also part of hyperkalemia management, in this emergent situation an ECG is the priority nursing assessment.
美國護理師在監測到鉀離子過高時，通常擁有更彈性的 protocol 可先行安排心電圖；台灣則需醫師下達醫囑後執行，但急診護理師常依經驗先行準備。