— 生理適應 · HARD · MCQ —
一位慢性腎臟病病人血鉀濃度為 6.2 mEq/L。護理師在評估時應優先注意哪項發現？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.2 mEq/L. Which finding should the nurse prioritize during assessment?
- AHyperactive bowel sounds腸蠕動亢進
- BIncreased urine output尿量增加
- CIrregular heart rhythm✓ 正解心律不整
- DComplaints of muscle fatigue肌肉疲勞的主訴
— Explanation · 中文詳解 —
高血鉀會導致心臟傳導異常，最嚴重的威脅是心室心律不整或心跳停止。心電圖常見 T 波高聳（Peaked T waves）、PR 間期延長及 QRS 波變寬。與腸胃道症狀或肌肉無力相比，心臟活動的穩定性直接關乎病人的生命安全，故為首要觀察目標。
Hyperkalemia causes abnormal cardiac conduction, with the most serious threat being ventricular dysrhythmias or cardiac arrest. Common ECG findings include peaked T waves, prolonged PR interval, and widened QRS complex. Compared with gastrointestinal symptoms or muscle weakness, the stability of cardiac activity is directly related to the client's survival, making it the top priority for observation.
✦ 台美臨床差異
美台臨床對於高血鉀緊急處理均高度重視，通常由 ICU 或急診團隊立即介入處理。