A client with end-stage renal disease is recovering in the post-anesthesia care unit (PACU) hours after the surgical creation of a left upper extremity arteriovenous (AV) fistula. The client suddenly reports profound weakness. The nurse notes deep, rapid respirations at breaths/minute. STAT laboratory results reveal a serum potassium of mEq/L and an arterial blood gas (ABG) showing pH , PaCO mm Hg, and HCO mEq/L. Which of the following actions should the nurse prioritize to mitigate the highest risk of mortality for this client?
- Initiate continuous electrocardiographic monitoring and prepare to administer intravenous calcium gluconate.Answer
- BCoach the client to slow their breathing rate and utilize a paper bag to prevent excessive carbon dioxide loss.
- CPrepare equipment for immediate endotracheal intubation to reverse the uncompensated respiratory acidosis.
- DPlace the client in a flat, supine position with the legs elevated to counteract the reported profound weakness.
Answer
The nurse must prioritize stabilizing the myocardial cell membrane to prevent fatal arrhythmias caused by critical hyperkalemia, which is achieved through continuous cardiac monitoring and the administration of intravenous calcium gluconate.
The client's serum potassium level of 6.8 mEq/L constitutes a medical emergency due to the high risk of fatal cardiac arrhythmias. The absolute priority is to stabilize the myocardial cell membrane with intravenous calcium gluconate while initiating continuous cardiac monitoring. The ABG results and Kussmaul respirations reflect a partially compensated metabolic acidosis typical of end-stage renal disease, which is secondary in acute lethality to the severe hyperkalemia.
Step-by-Step Solution
Key Concept
Prioritization of care in severe hyperkalemia and interpretation of compensatory Kussmaul respirations in metabolic acidosis.