— 生理適應 · MEDIUM · MCQ —
一位高血鉀症病人，護理師應優先評估下列哪項臨床發現？
A nurse is caring for a client with hyperkalemia. Which finding is the most critical for the nurse to assess first?
- AIrregular heart rhythm on the monitor✓ 正解監視器顯示心律不整
- BPresence of muscle weakness出現肌肉無力
- CReports of abdominal cramping主訴腹部絞痛
- DSerum potassium level of 6.2 mEq/L血清鉀濃度為 6.2 mEq/L
— Explanation · 中文詳解 —
高血鉀最致命的併發症為心律不整，因其會導致心室顫動或心搏停止。護理師應優先評估心電圖變化，以避免生命徵象惡化。B、C雖為高血鉀常見徵象，但相較於心臟功能，心跳節律屬於生命安全最優先的 ABC 評估範疇。
Hyperkalemia poses the greatest immediate threat to life through cardiac dysrhythmias, which can progress to ventricular fibrillation or asystole. Therefore, assessing the cardiac monitor for irregular rhythms is the highest priority, as it directly reflects the patient's hemodynamic stability compared to other symptoms like muscle weakness or gastrointestinal cramping.
✦ 台美臨床差異
美國護理師依 protocol 使用校準過的監測儀監控，台灣護理師則高度依賴醫囑判斷心電圖節律。