# 一位急性腎損傷個案的血鉀值為 6.4 mEq/L，且心臟監視器上出現高聳 T 波。護理師應首先執行哪項醫囑？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397321&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位急性腎損傷個案的血鉀值為 6.4 mEq/L，且心臟監視器上出現高聳 T 波。護理師應首先執行哪項醫囑？

## 選項

1. 鼓勵食用高鉀點心。
2. 隨餐給予磷結合劑。
3. 收集常規尿液檢體。
4. 依醫囑給予靜脈注射 calcium gluconate。 **✔ 正確答案**

**正確答案: 4**

## 解析

嚴重高血鉀伴隨心電圖變化會威脅心臟穩定性。靜脈注射 calcium gluconate 可穩定心肌，是醫囑開立時的優先處置。飲食中的鉀、常規檢體和磷結合劑無法處理立即的心律不整風險。

## 深入解析

臨床判斷
使用個案線索、時間點、檢驗數據和安全風險，選擇最符合高血鉀伴隨心電圖變化情境的回應。

記憶提示
將最強的線索群與最安全的護理判斷配對。

KR vs US
NCLEX 考題獎勵基於線索的優先思考，而非單獨的回憶。

## 臨床情境

臨床實務指引
對於高血鉀伴隨心電圖變化，將完整的線索模式與個案當前的穩定性、醫囑數據和預期的護理範圍進行比較。

注意
當完整情境改變了優先順序或安全性時，不要僅根據單一線索選擇行動。

## 重要概念

- **高血鉀** — 血清鉀離子升高，可能導致危及生命的心律不整。
- **高聳 T 波** — 一種與高血鉀相關的心電圖變化。
- **Calcium Gluconate** — 一種在嚴重高血鉀時用於穩定心肌細胞膜的藥物。

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