— 生理適應 · MEDIUM · MCQ —
護理師照顧一位高血鉀病人，下列哪項評估發現需要立即通知醫師？
A nurse is caring for a client with hyperkalemia. Which assessment finding requires immediate notification to the provider?
- ADecreased bowel sounds腸蠕�音減弱
- BMuscle weakness in the lower extremities下肢肌肉無力
- CReports of tingling in the fingers指尖刺痛感
- DPeaked T waves on the ECG✓ 正解心電圖呈現高尖 T 波
— Explanation · 中文詳解 —
高血鉀（Hyperkalemia）會顯著影響心肌細胞的去極化與再極化，心電圖（ECG）變化是高血鉀最危險的臨床指標。高尖 T 波（Peaked T waves）代表血鉀濃度已達到可能導致嚴重致命性心律不整（如心室顫動或心搏停止）的水平。護理師必須將其視為緊急醫療狀況，立即通知醫師採取藥物介入（如鈣劑、胰島素或葡萄糖）。
Peaked T waves on the electrocardiogram indicate critical cardiac instability and a high risk for fatal arrhythmias such as ventricular fibrillation or cardiac arrest. This finding requires immediate notification of the provider to initiate urgent interventions like calcium gluconate or insulin with glucose.