— 生理適應 · HARD · MCQ —
病人鉀離子濃度為 6.5 mEq/L 入院，護理師應優先採取哪項措施？
A client is admitted with a potassium level of 6.5 mEq/L. Which intervention should the nurse perform first?
- AAdminister sodium polystyrene sulfonate給予聚苯乙烯磺酸鈉
- BEncourage oral fluid intake鼓勵口服液體攝取
- CAdminister IV insulin and dextrose給予靜脈注射胰島素和葡萄糖
- DPlace the client on a cardiac monitor✓ 正解將病人連接心電圖監測儀
— Explanation · 中文詳解 —
高血鉀（Hyperkalemia）最嚴重且致命的併發症是致命性心律不整（如心室顫動、心搏停止）。當血鉀達到 6.5 mEq/L 時，心臟傳導系統已處於高風險狀態。因此，護理師的首要行動必須是連接心電圖監測（Cardiac monitor），以便即時觀察心率與節律變化，這是保障病人生命安全的最優先步驟。
Hyperkalemia poses an immediate risk of life-threatening cardiac dysrhythmias, such as ventricular fibrillation or asystole. Therefore, the nurse's priority intervention is to place the client on a cardiac monitor to detect any changes in heart rhythm instantly, ensuring patient safety before administering treatments that take longer to lower potassium levels.