— 生理適應 · MEDIUM · MCQ —
一位病患診斷為低血鉀，給予靜脈注射氯化鉀前，護理師最關鍵的評估為何？
A client is diagnosed with hypokalemia. Which nursing action is most critical prior to administering intravenous potassium chloride?
- AVerify that the client is voiding at least 30 mL/hr✓ 正解確認病人每小時排尿量至少 30 mL
- BAssess for peripheral edema評估周邊水腫
- CCheck the client's blood pressure測量病人血壓
- DObtain a baseline electrocardiogram取得基線心電圖
— Explanation · 中文詳解 —
靜脈給予鉀離子風險極高，若腎功能不佳（無尿或少尿）會導致致命性高血鉀。確保尿量 > 30 mL/hr 是確認腎臟排泄功能正常的必要安全檢查。心電圖雖重要，但在給藥前確認排泄途徑暢通是更根本的護理職責。
Intravenous administration of potassium carries a very high risk: impaired renal function (anuria or oliguria) can lead to fatal hyperkalemia. Verifying urine output greater than 30 mL/hr is the essential safety check to confirm normal renal excretory function. Although an electrocardiogram is important, confirming a patent route of excretion prior to administration is the more fundamental nursing responsibility.
✦ 台美臨床差異
美台臨床皆嚴格遵守此安全規範，但台灣在給予高濃度鉀離子時，常要求建立專用靜脈管路以避免滲漏。