— 照護管理 · MEDIUM · SATA —
護理師照顧一位鉀離子濃度為 2.8 mEq/L 的病人。應採取哪些措施？（選所有適合的）
A nurse is caring for a client with a potassium level of 2.8 mEq/L. Which actions should the nurse take? (Select all that apply.)
- APlace the client on a cardiac monitor✓ 正解將病人安置於心電監護儀上
- BAdminister IV potassium push rapidly快速靜脈推注鉀離子
- CMonitor for muscle weakness and cramping✓ 正解監測肌肉無力與痙攣
- DAssess deep tendon reflexes✓ 正解評估深層肌腱反射
- EEncourage intake of foods like bananas and oranges✓ 正解鼓勵攝取香蕉和柳橙等食物
— Explanation · 中文詳解 —
低血鉀（2.8 mEq/L）可能導致致命性心律不整。A 項：必須監測心電圖。C 項：低血鉀常伴隨肌肉無力。D 項：反射異常是常見表徵。E 項：提供富含鉀的食物。B 錯誤：絕對禁止靜脈推注（IV Push）鉀離子，這會直接導致心跳停止，鉀離子補充必須稀釋並透過點滴緩慢給予。
Hypokalemia significantly increases the risk of life-threatening cardiac arrhythmias, necessitating continuous cardiac monitoring. Clinical manifestations include muscle weakness, cramping, and altered deep tendon reflexes due to impaired nerve impulse conduction. While IV potassium must never be given as a rapid push, encouraging dietary intake of potassium-rich foods is a safe adjunctive measure.
✦ 台美臨床差異
台美對於鉀離子補充的給藥途徑規定皆極嚴格，但在美國，IV 鉀補充常有特定的給藥 Protocol，護理師需嚴格執行。