— 生理適應 · MEDIUM · SATA —
一位病患診斷為低血鉀，護理師應執行哪些介入措施？（選所有適合的）
A client is diagnosed with hypokalemia. Which interventions should the nurse perform? (Select all that apply.)
- AAdminister potassium chloride IV push靜脈推注氯化鉀
- BMonitor electrocardiogram (ECG) for U waves✓ 正解監測心電圖（ECG）是否有 U 波出現
- CAssess respiratory rate and depth✓ 正解評估呼吸頻率與深度
- DEncourage consumption of bananas and oranges✓ 正解鼓勵食用香蕉與柳橙
- ECheck the IV site for infiltration if infusing potassium✓ 正解若正在輸注鉀離子，檢查靜脈注射部位是否有滲漏
— Explanation · 中文詳解 —
低血鉀影響神經肌肉傳導與心肌電生理。心電圖可見 U 波、ST 下降。呼吸肌無力需密切評估。補充鉀離子需攝取含鉀食物，靜脈輸注時需嚴格監控且不可直接靜脈推注（IV Push），因鉀離子具強烈刺激性，漏出血管會導致嚴重組織壞死，故需定時檢查注射部位。
Hypokalemia affects neuromuscular and cardiac function, so monitoring for ECG changes like U waves is essential. Since respiratory muscles can weaken, assessing respiratory rate and depth is critical. Potassium-rich foods such as bananas and oranges help replenish levels safely, while IV potassium must never be given as a push due to cardiac arrest risks. Additionally, checking the IV site is necessary because potassium is highly irritating to veins.
✦ 台美臨床差異
美台臨床皆嚴禁鉀離子靜脈推注，台灣針對鉀離子補充的給藥速度監控有嚴格的單位 protocol。