— 生理適應 · HARD · SATA —
護理師照護高血鉀病患，應執行哪些介入措施？（選所有適合的）
A nurse is caring for a client with hyperkalemia. Which interventions should the nurse perform? (Select all that apply.)
- AAdminister intravenous calcium gluconate✓ 正解給藥靜脈注射葡萄糖酸鈣
- BPrepare for the administration of insulin and glucose✓ 正解準備給藥胰島素與葡萄糖
- CAdminister oral potassium supplements給藥口服鉀補充劑
- DPrepare for hemodialysis if severe✓ 正解若情況嚴重，準備血液透析
- EInitiate continuous cardiac monitoring✓ 正解開始連續心臟監測
— Explanation · 中文詳解 —
高血鉀處理原則：保護心肌（Calcium gluconate）、將鉀移入細胞內（Insulin + Dextrose）、排除過多鉀離子（透析或利尿劑）。絕不可給予額外鉀離子補充，且因電解質失衡極易引發致命心律不整，必須進行心電圖連續監測。
Principles of hyperkalemia management: protect the myocardium (calcium gluconate), shift potassium into the cells (insulin plus dextrose), and remove excess potassium (dialysis or diuretics). Additional potassium supplementation must never be given; and because electrolyte imbalance can readily precipitate fatal arrhythmias, continuous ECG monitoring is required.
✦ 台美臨床差異
美台臨床對高血鉀處理流程高度一致，皆遵循保護心肌至移除鉀離子的步驟。