— 生理適應 · HARD · MCQ —
一位護理師照護低血鉀病患。下列哪項評估發現最需優先注意？
A nurse is caring for a client with hypokalemia. Which assessment finding should the nurse prioritize?
- AIrregular heart rhythm on the telemetry monitor✓ 正解監測儀上出現心律不整
- BDecreased bowel sounds腸鳴音減弱
- CMuscle weakness in the lower extremities下肢肌肉無力
- DDry mucous membranes黏膜乾燥
— Explanation · 中文詳解 —
低血鉀最致命的併發症是心律不整，因為鉀離子會影響心肌電生理。心電圖可能出現 U 波、T 波倒置或心律不齊。肌無力與腸蠕動減慢雖為常見臨床徵象，但在優先順序上，維持血流動力學穩定（心律）遠高於肌肉骨骼功能。
Cardiac arrhythmias are the most life-threatening complication of hypokalemia because potassium is critical for myocardial electrophysiology. Although muscle weakness and decreased bowel sounds are common signs, maintaining hemodynamic stability takes priority over other symptoms.
✦ 台美臨床差異
美台護理臨床皆強調低血鉀監測心律之重要性。