— 生理適應 · HARD · MCQ —
一位慢性腎臟病病人血鉀濃度為 6.2 mEq/L。護理師應優先採取什麼行動？
A client with chronic kidney disease (CKD) has a potassium level of 6.2 mEq/L. Which intervention should the nurse prioritize?
- AEncourage increased fluid intake鼓勵增加液體攝取
- BAdminister oral potassium supplement給予口服鉀補充劑
- CPlace the client on a cardiac monitor✓ 正解將病人連接至心臟監護儀
- DIncrease dietary potassium intake增加膳食鉀攝取
— Explanation · 中文詳解 —
血鉀 6.2 mEq/L 屬於高血鉀症，危險在於引發致死性心律不整。優先措施是裝上心電圖監測，以隨時觀察是否有 T 波變尖或 QRS 波變寬等危險徵象。補充或增加攝取鉀離子會加重病情，水分攝取對腎功能不佳者有風險。
With a potassium level of 6.2 mEq/L, the nurse must prioritize placing the client on a cardiac monitor to detect life-threatening arrhythmias such as peaked T waves or widened QRS complexes. Hyperkalemia poses an immediate risk to cardiac stability, making continuous monitoring the most critical intervention.
✦ 台美臨床差異
此類危急值在兩地均需立即通知醫師並依醫囑給予降鉀藥物（如 Kayexalate 或胰島素加葡萄糖），流程大同小異。