一位慢性腎臟病（CKD）患者血鉀濃度為 6.5 mEq/L。護理師在評估時應優先注意哪項發現？
A client with chronic kidney disease (CKD) has a serum potassium level of 6.5 mEq/L. Which finding should the nurse prioritize during assessment?
- ADecreased bowel sounds腸鳴音減弱
- BClient report of nausea and vomiting病人主訴噁心與嘔吐
- CComplaints of generalized muscle weakness抱怨全身性肌肉無力
- DPresence of peaked T waves on ECG✓ 正解心電圖上出現尖峰 T 波
高血鉀（Hyperkalemia）最致命的併發症是心律不整，血鉀 6.5 mEq/L 已達危險程度。心電圖顯示的高 T 波（Peaked T waves）是心肌電位傳導異常的早期徵兆，隨後可能演變成心室纖維顫動或心跳停止。護理師必須根據 ABC（Airway, Breathing, Circulation）原則，優先評估循環系統的穩定性。其他症狀如肌肉無力、噁心嘔吐雖然是高血鉀的常見臨床表現，但並不直接造成立即的生命危險。處理此類個案時，確保心電圖監測與準備鈣劑（Calcium Gluconate）來穩定心肌細胞膜是緊急護理之核心任務，防止電解質不平衡引發猝死。
Peaked T waves on an ECG are the priority finding as they indicate life-threatening cardiac electrical instability due to hyperkalemia. Although muscle weakness and gastrointestinal symptoms are associated with elevated potassium levels, cardiac changes pose the most immediate risk of fatal arrhythmias such as ventricular fibrillation.
美國護理教育強調在發現異常心電圖時，護理師需具備識別並立即通知 Rapid Response Team 的授權。台灣則較為強調由護理師先進行初步心電圖判讀並聯絡值班醫師（Resident），決策過程較為階層化。