— 生理適應 · MEDIUM · MCQ —
護理師照顧一位血鉀濃度 6.5 mEq/L 的病患。下列何種評估發現最令人擔憂？
A nurse is caring for a client with a serum potassium level of 6.5 mEq/L. Which assessment finding is most concerning?
- ANumbness in the fingers手指麻木
- BHyperactive bowel sounds腸鳴音亢進
- CMuscle weakness肌肉無力
- DIrregular heart rhythm✓ 正解心律不整
— Explanation · 中文詳解 —
高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傳導。6.5 mEq/L 屬於嚴重高血鉀，極易引發心室顫動或心搏停止。心電圖變化包括 T 波高聳、QRS 波變寬，護理師必須密切監控心臟活動並準備緊急降鉀治療。
Hyperkalemia significantly affects cardiac conduction, making irregular heart rhythms the most critical and life-threatening complication. A serum potassium level of 6.5 mEq/L poses a high risk for severe arrhythmias, such as ventricular fibrillation or cardiac arrest. Therefore, continuous cardiac monitoring is essential to detect changes like peaked T waves or widened QRS complexes promptly.
✦ 台美臨床差異
美國護理師可預先執行心電圖監測；台灣護理師需醫師確認異常後，才進行緊急藥物降鉀措施。