— 生理適應 · EASY · MCQ —
一位病人的血鉀值為 6.2 mEq/L。下列哪項是該病人的首要護理干預？
A client is admitted with a potassium level of 6.2 mEq/L. Which of the following is the priority intervention for this client?
- AAdminister oral potassium-lowering resin (Kayexalate)口服降鉀離子交換樹脂（Kayexalate）
- BTeach the client about a low-potassium diet教導客戶低鉀飲食
- CPrepare the client for emergency hemodialysis準備病人進行緊急血液透析
- DObtain an immediate 12-lead electrocardiogram (ECG)✓ 正解立即取得十二導程心電圖（ECG）
— Explanation · 中文詳解 —
血鉀 6.2 mEq/L 屬於嚴重高鉀血症，會直接影響心肌去極化，導致致命性心律不整（如心室顫動）。護理首要是立即監測心臟電生理變化（ECG），以決定是否需要給予葡萄糖酸鈣保護心臟。Kayexalate 緩慢，洗腎為後續手段，衛教不具緊急性。
With a potassium level of 6.2 mEq/L, the priority intervention is to obtain an immediate 12-lead electrocardiogram to assess for life-threatening cardiac arrhythmias caused by hyperkalemia. While treatments like Kayexalate or dialysis may be necessary, they act too slowly or are secondary to the immediate need for cardiac monitoring and stabilization.
✦ 台美臨床差異
美國 NCLEX 強調評估（Assessment）優先於行動；台灣臨床實務常會先執行醫囑給予降鉀藥物，但考題逻辑一致。