— 生理適應 · MEDIUM · MCQ —
護理師照護一位低血鉀病患，哪項評估發現最令護理師擔憂？
A nurse is caring for a client with hypokalemia. Which assessment finding is most concerning to the nurse?
- AMuscle weakness肌肉無力
- BIncreased thirst口渴增加
- CDecreased bowel sounds腸鳴音減少
- DIrregular heart rate✓ 正解心律不整
— Explanation · 中文詳解 —
鉀離子對心肌電生理傳導至關重要。低血鉀會導致心律不整，這是威脅生命的緊急情況（ABC 原則中的循環評估）。肌肉無力與腸蠕動減少是常見表現，雖需處理，但心律異常直接導致心輸出量下降與休克風險，優先度最高。
An irregular heart rate is the most concerning finding because hypokalemia can cause life-threatening cardiac dysrhythmias that may lead to cardiac arrest. Although muscle weakness and decreased bowel sounds are common symptoms of low potassium, they are less immediately dangerous than potential circulatory compromise.
✦ 台美臨床差異
美台兩地在補鉀過程中皆強調必須確認腎功能正常且有尿液輸出，預防高血鉀醫源性傷害。