一位病人的血清鉀離子濃度為 6.5 mEq/L。護理師應優先監測哪項評估結果？
A client presents with a serum potassium level of 6.5 mEq/L. Which assessment finding is the priority for the nurse to monitor?
- AMuscle weakness in the lower extremities下肢肌肉無力
- BHyperactive bowel sounds腸鳴音亢進
- CCardiac rhythm changes on the monitor✓ 正解監測器上之心律變化
- DIncreased urinary output尿量增加
高血鉀（>5.0 mEq/L）最嚴重的併發症是心律不整，包含 T 波高尖、PR 間期延長、QRS 增寬，甚至心室顫動或心跳停止。雖然高血鉀也會引起腸鳴音亢進（B）或肌肉無力（A），但心臟穩定性是維生安全的最優先考量（ABC 原則）。
Hyperkalemia poses the greatest risk for life-threatening cardiac dysrhythmias, such as ventricular fibrillation or cardiac arrest, making cardiac monitoring the priority assessment. Although symptoms like muscle weakness or hyperactive bowel sounds may occur, they are less critical than potential cardiac instability. Following the ABC (Airway, Breathing, Circulation) principle, ensuring cardiac stability is the nurse's primary concern.
美國 NCLEX 強調評估與介入的優先順序（Safety/Risk reduction）；台灣臨床實務中，檢驗值異常通常需立即通報醫師並執行醫囑給予降鉀藥物。