— 生理適應 · MEDIUM · MCQ —
一位低血鉀病人正接受靜脈輸注氯化鉀，哪項評估發現是護理師需優先處理的重點？
A client with hypokalemia is receiving an intravenous potassium chloride infusion. Which assessment finding is the highest priority for the nurse to address?
- APatient complains of generalized muscle weakness病人主訴全身肌肉無力
- BPatient demonstrates weak peripheral pulses病人周邊脈搏微弱
- CPatient reports mild burning at the IV site病人報告靜脈注射部位有輕微灼熱感
- DPatient's urine output is 15 mL/hour over the last 2 hours✓ 正解過去兩小時內病人尿量為 15 mL/小時
— Explanation · 中文詳解 —
低血鉀補鉀前必須確定腎功能正常。每小時尿量少於 30 mL 顯示腎功能不佳，若此時輸注鉀離子極易導致嚴重高血鉀與致命性心律不整。A 為常見輸注不適但非致命；B 與 A 是低血鉀的臨床表現，輸注中會逐漸改善，唯獨腎功能是給藥前的絕對安全前提。
Urine output of less than 30 mL/hour indicates impaired renal function, which is a critical contraindication for potassium replacement. Since the kidneys are responsible for excreting excess potassium, administering potassium with inadequate urine output poses a high risk for fatal hyperkalemia and cardiac arrhythmias.
✦ 台美臨床差異
美台皆嚴格執行給鉀前確認尿量之安全守則，但美國多有自動化提醒機制。