— 生理適應 · MEDIUM · MCQ —
護理師照顧一名低血鉀病患。哪項發現應優先評估？
A nurse is caring for a client with hypokalemia. Which finding should the nurse prioritize for assessment?
- AGeneralized fatigue全身性疲倦
- BPresence of muscle weakness肌肉無力
- CIrregular heart rate on the monitor✓ 正解監護儀上心律不整
- DDecreased bowel sounds腸鳴音減弱
— Explanation · 中文詳解 —
低血鉀（Hypokalemia）會導致心肌細胞膜電位不穩定，嚴重影響心臟傳導系統。在 NCLEX 考試中，處理「生理適應」問題應優先考量 ABC（呼吸道、呼吸、循環）。心律不整代表循環系統功能受損，若未即時發現或處理，極可能進展為致命性的心室顫動（Ventricular Fibrillation）或心跳停止，因此是護理評估中最優先的危機項目。
Hypokalemia destabilizes myocardial cell membranes and disrupts cardiac conduction, posing a risk for lethal dysrhythmias such as ventricular fibrillation. According to the ABC priority framework, cardiac instability takes precedence over non-specific symptoms like fatigue or muscle weakness. Therefore, an irregular heart rate requires immediate assessment and intervention to prevent hemodynamic collapse.