— 生理適應 · MEDIUM · MCQ —
對於低鉀血症的病人，下列哪項評估結果需要護理師立即介入？
Which assessment finding in a client with hypokalemia requires immediate nurse intervention?
- ADecreased bowel sounds腸鳴音減弱
- BIrregular heart rhythm on telemetry✓ 正解遠距監護顯示心律不整
- CGeneralized fatigue全身性疲倦
- DMuscle cramps in the calf小腿肌肉痙攣
— Explanation · 中文詳解 —
電解質失衡中，心律不整對病人生命威脅最大。低鉀會導致心肌興奮性改變，產生心室顫動或心室頻脈等危及生命的心律不整。相較於肌肉痙攣或腸蠕動變慢，心律穩定是 ABC 中的 Circulation 首要考量。
Hypokalemia significantly increases the risk of life-threatening cardiac dysrhythmias due to altered myocardial excitability. An irregular heart rhythm on telemetry requires immediate intervention to prevent serious complications like ventricular fibrillation.
✦ 台美臨床差異
美國護理師常依據 Protocol 直接給予補鉀藥物，台灣則多需醫師確認血鉀數值並開立處方後執行。