# 急性白血病誘導化療後 12 小時，哪項發現需要護理師立即採取行動？ > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=498854&lang=zh-tw > language: zh-TW > subject: Adverse Effects/Contraindications/Interactions > category: PA ## 題目 急性白血病誘導化療後 12 小時，哪項發現需要護理師立即採取行動？ ## 選項 1. 血紅素 8.9 g/dL，伴隨走到浴室時的疲倦 2. 血小板計數 86,000/mm3，伴隨雙前臂散在瘀傷 3. 鉀離子 6.2 mEq/L，伴隨心臟監視器上新的尖峰 T 波 **✔ 正確答案** 4. 白血球計數 2,900/mm3，伴隨口腔溫度 37.2°C **正確答案: 3** ## 解析 快速腫瘤崩解可釋放細胞內鉀離子，並導致致命性心律不整。鉀離子 6.2 mEq/L 伴隨尖峰 T 波是活躍的心臟急症，需要立即通報、監測及處方治療。 ## 深入解析 快速解答 將伴隨心電圖變化的高血鉀視為立即的腫瘤溶解急症處理。 為什麼這是正確的 誘導治療可一次摧毀許多惡性細胞，釋放鉀離子、磷酸鹽及核酸。尖峰 T 波顯示升高的鉀離子已影響心臟傳導，因此穩定措施不能等待常規追蹤。 簡單比喻或心智圖像 腫瘤溶解就像許多儲存細胞同時破裂，淹沒電氣系統。此類比強調突然的電解質負荷，但無法取代鉀離子、磷酸鹽、鈣、尿酸及腎功能的測量。 記憶掛鉤 化療後，高血鉀加上心電圖變化意味著立即行動。 NCLEX 決策規則 當檢驗異常伴隨現存的器官功能障礙時，優先處理。在疑似腫瘤溶解症候群中，心律不整風險優先於穩定的貧血、非危急的血小板減少或無發燒的白血球減少。 為什麼其他選項是錯的 貧血及血小板減少需要追蹤，但未顯示立即的不穩定。白血球減少增加感染風險，但所列的體溫並未顯示發燒。參考文獻 - [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing - [2]NCI Dictionary of Cancer Terms: Tumor Lysis SyndromeNational Cancer Institute - [3]Tumor Lysis SyndromeNational Library of Medicine Bookshelf ## 相同主題題目 - [A nurse is reviewing the morning lab results for an adult client receiving warfarin for at…](https://mymerci.kr/pages/nclex_q.php?qn_id=360515&lang=zh-tw) - [A client is admitted to the emergency department after ingesting an unknown amount of acet…](https://mymerci.kr/pages/nclex_q.php?qn_id=362720&lang=zh-tw) - [A client with chronic heart failure is prescribed metoprolol 25 mg orally twice daily. Bef…](https://mymerci.kr/pages/nclex_q.php?qn_id=362756&lang=zh-tw) - [A 28-year-old client with type 1 diabetes receives regular insulin 6 units and NPH insulin…](https://mymerci.kr/pages/nclex_q.php?qn_id=362792&lang=zh-tw) - [A client receives IV vancomycin 1 g every 12 hours for MRSA bacteremia. Before the next do…](https://mymerci.kr/pages/nclex_q.php?qn_id=362833&lang=zh-tw) - [A client with bipolar disorder has been taking lithium carbonate 600 mg orally three times…](https://mymerci.kr/pages/nclex_q.php?qn_id=362894&lang=zh-tw) - [An 80-year-old male with heart failure is prescribed digoxin 0.125 mg daily. During mornin…](https://mymerci.kr/pages/nclex_q.php?qn_id=372686&lang=zh-tw) - [A 38-year-old female with rheumatoid arthritis is being discharged with a new prescription…](https://mymerci.kr/pages/nclex_q.php?qn_id=372687&lang=zh-tw) ## 以其他語言閱讀 - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=498854&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=498854&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=498854&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=498854&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=498854&lang=vi) --- More free questions: [NCLEX-RN 題庫](https://mymerci.kr/pages/nclex_bank.php?lang=zh-tw) _僅供學習參考。實際臨床請遵循最新指引與所屬機構規範。_