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Difficulty: Very hardPhysiological Adaptation

A triage nurse in the emergency department receives a client with acute kidney injury secondary to severe rhabdomyolysis. The client reports profound muscle weakness. A STAT 12-lead electrocardiogram reveals absent P waves, a heart rate of 42 bpm42\text{ bpm}, and markedly widened QRS complexes. Arrange the following nursing actions in the most appropriate priority order from first to last.

  1. 1Place the client on a continuous cardiac monitor.
  2. 2Administer intravenous calcium gluconate.
  3. 3Administer intravenous regular insulin and 50%50\% dextrose.
  4. 4Administer oral sodium polystyrene sulfonate.
  5. 5Draw blood for a repeat serum potassium level.

Answer

The correct order is: Place the client on a continuous cardiac monitor, followed by administering IV calcium gluconate, then IV regular insulin with dextrose, then oral sodium polystyrene sulfonate, and finally drawing blood for a repeat potassium level.
The correct sequence aligns with the principles of acute physiological resuscitation: immediate safety monitoring (ECG), rapid stabilization of vital organ function (Calcium for the myocardium), acute temporizing treatment (Insulin/Dextrose for shifting), delayed definitive treatment (Sodium polystyrene sulfonate for elimination), and post-intervention evaluation (Repeat labs).

Step-by-Step Solution

1
Ensure continuous visualization of the cardiac rhythm.
The client is placed on a continuous cardiac monitor with defibrillator pads readily available.
The client has a symptomatic, life-threatening arrhythmia due to severe hyperkalemia. Continuous monitoring is required to immediately detect deterioration into a lethal arrhythmia.
2
Initiate myocardial membrane stabilization.
Intravenous calcium gluconate is administered.
Calcium gluconate is the absolute first-line pharmacological agent for hyperkalemia with ECG changes. It does not lower potassium but raises the myocardial threshold potential, protecting the heart from ventricular fibrillation within minutes.
3
Initiate intracellular potassium shifting.
Intravenous regular insulin and 50% dextrose are administered.
Once the myocardium is stabilized, the next priority is to rapidly lower the serum potassium level. Insulin drives potassium into cells (working in 15-30 minutes), and dextrose prevents profound hypoglycemia.
4
Initiate definitive potassium elimination.
Sodium polystyrene sulfonate is administered.
After temporizing measures are completed, a medication that permanently removes potassium from the gastrointestinal tract is given. Because this resin takes hours to days to significantly lower serum levels, it cannot be given before stabilization.
5
Evaluate the response to therapeutic interventions.
Blood is drawn for a repeat serum potassium level and basic metabolic panel.
Evaluation is the final step of the acute nursing process to determine if extracellular potassium has shifted adequately or if emergent hemodialysis is now required.

Key Concept

The physiological sequencing of hyperkalemia management prioritizes myocardial stabilization, followed by intracellular shifting, and finally bodily elimination.
Estimated Time:2m 0s
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Physiological Adaptation

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