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Difficulty: MediumPhysiological Adaptation

A triage nurse is assessing a client with a history of chronic kidney disease who missed their last two hemodialysis sessions. The client reports profound muscle weakness and tingling in the extremities. An immediate electrocardiogram (ECG) reveals a prolonged PR interval, a widened QRS complex, and tall, peaked T waves. The serum potassium level is reported as 7.4 mEq/L. Which of the following prescribed interventions should the nurse implement first?

  1. Administer intravenous calcium gluconate.Answer
  2. B
    Administer intravenous regular insulin and dextrose.
  3. C
    Administer oral sodium polystyrene sulfonate.
  4. D
    Initiate a concurrent infusion of sodium bicarbonate and calcium gluconate through the same intravenous line.

Answer

Administer intravenous calcium gluconate.
The client is experiencing a life-threatening physiological emergency due to severe hyperkalemia. The widening of the QRS complex indicates that the high potassium level is disrupting ventricular depolarization, placing the client at imminent risk for a lethal dysrhythmia, such as ventricular fibrillation or asystole. The absolute highest priority is to stabilize the myocardial cell membrane. Intravenous calcium gluconate works rapidly (within minutes) to raise the threshold potential of cardiac myocytes, protecting the heart. Once the heart is protected, the nurse will then administer agents to shift potassium into the cells (insulin/dextrose) and remove it from the body (hemodialysis or sodium polystyrene sulfonate).

Step-by-Step Solution

1
Identify the clinical emergency from the assessment data.
The client has severe hyperkalemia (7.4 mEq/L) with significant cardiac manifestations, including a widened QRS complex and peaked T waves.
A widened QRS complex indicates severely impaired ventricular depolarization, placing the client at imminent risk for lethal dysrhythmias such as ventricular fibrillation or asystole.
2
Determine the physiological priority.
Protecting the heart from lethal dysrhythmias takes precedence over shifting or removing the excess potassium.
According to the ABCs (Airway, Breathing, Circulation) and survival principles, preventing cardiac arrest is the most immediate life-saving action.
3
Select the appropriate intervention that matches the priority.
Intravenous calcium gluconate is identified as the correct first action.
Calcium directly antagonizes the membrane-depolarizing effects of potassium, stabilizing the myocardium within minutes.

Key Concept

Prioritization of life-threatening hyperkalemia with cardiac manifestations.
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Topics

Physiological Adaptation

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