— 生理適應 · HARD · MCQ —
一位鉀離子濃度為 6.2 mEq/L 的病人入院。護理師應優先採取的行動為何？
A client with a potassium level of 6.2 mEq/L is admitted. Which priority action should the nurse take?
- AObtain an EKG tracing✓ 正解取得心電圖（EKG）紀錄
- BAdminister a potassium supplement給予鉀離子補充劑
- CEncourage oral intake of fluids鼓勵口服攝取液體
- DAssess the client for peripheral edema評估個案周邊水腫情形
— Explanation · 中文詳解 —
鉀離子過高（6.2 mEq/L，正常 3.5-5.0）最嚴重的併發症是致命性心律不整。護理師應優先評估心電圖（EKG）是否有高聳 T 波（Peaked T-waves）等變化。C 會使鉀增加，B 會導致病況惡化，D 非優先項目。
Elevated potassium (6.2 mEq/L; normal 3.5–5.0) is most seriously associated with the complication of fatal arrhythmia. The nurse should first assess the electrocardiogram (ECG) for changes such as peaked T waves. Option C would further increase potassium; Option B would worsen the condition; Option D is not a priority.
✦ 台美臨床差異
美國護理師依 protocol 執行心電圖檢查並通知醫師；台灣臨床亦相同，但處理高血鉀的藥物執行需嚴格確認醫囑。