— 生理適應 · MEDIUM · MCQ —
一位嚴重燒傷病人處於急救期（Emergent phase）。預期會出現哪種電解質移轉？
A client with a severe burn injury is in the emergent phase. Which electrolyte shift is expected?
- AHypernatremia and hypokalemia高血鈉和低血鉀
- BHypocalcemia and hypermagnesemia低血鈣和高血鎂
- CHypernatremia and hyperkalemia高血鈉和高血鉀
- DHyponatremia and hyperkalemia✓ 正解低血鈉和高血鉀
— Explanation · 中文詳解 —
燒傷後的急救期（Emergent/Resuscitative phase）通常指受傷後的前 24 至 48 小時。此時細胞膜受損，導致細胞內的鉀離子大量釋放至細胞外液（Hyperkalemia），這是最致命的電解質失衡。同時，由於血管通透性增加，水分與鈉離子大量從血管滲漏至組織間隙，導致血管內液減少與稀釋性低血鈉（Hyponatremia）。護理師應密切監測病人的心電圖（鉀離子過高可能引起致命心律不整）與液體復甦情況（Fluid Resuscitation）。
The sterile field must remain within the nurse's constant line of sight to ensure it is not contaminated by unseen particles or unauthorized contact. Leaving the area unattended, placing items below waist level, or reaching over the sterile field compromises sterility and requires the setup to be restarted.