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Difficulty: HardPhysiological Adaptation

A nurse in the emergency department is caring for a client with end-stage kidney disease who missed their last two scheduled hemodialysis sessions. The client presents with profound muscle weakness, lethargy, and a heart rate of 52 beats per minute. The cardiac monitor displays widened QRS complexes and peaked T waves. Arterial blood gas (ABG) analysis on room air reveals a pH of 7.29, PaCO2 33 mm Hg, HCO3 15 mEq/L, and PaO2 96 mm Hg. Which of the following immediate interventions should the nurse anticipate? Select all that apply.

  1. Administer intravenous calcium gluconate.Answer
  2. Administer intravenous regular insulin concurrently with 50% dextrose.Answer
  3. C
    Instruct the client to breathe slowly into a paper bag.
  4. Prepare the client for emergent hemodialysis.Answer
  5. E
    Administer an oral dose of sodium polystyrene sulfonate.

Answer

The correct interventions are administering intravenous calcium gluconate, administering intravenous regular insulin with 50% dextrose, and preparing the client for emergent hemodialysis.
The client is experiencing symptomatic hyperkalemia (widened QRS, peaked T waves) and metabolic acidosis secondary to missed hemodialysis. Immediate treatment requires stabilizing the cardiac membrane with calcium gluconate, temporarily shifting potassium into cells with regular insulin and dextrose, and definitively removing potassium and restoring acid-base balance via emergent hemodialysis.

Step-by-Step Solution

1
Analyze the client's clinical presentation and electrocardiogram (ECG) findings.
The missed dialysis, weakness, bradycardia, widened QRS complexes, and peaked T waves indicate severe, life-threatening hyperkalemia.
Identifying the primary life-threatening condition dictates immediate priority interventions.
2
Interpret the arterial blood gas (ABG) results.
A pH of 7.29 and HCO3 of 15 mEq/L indicate metabolic acidosis. The PaCO2 of 33 mm Hg indicates respiratory compensation.
Understanding the acid-base imbalance determines if respiratory interventions are appropriate or contraindicated.
3
Select interventions that rapidly address the hyperkalemia and cardiac instability.
Calcium gluconate stabilizes the myocardium, insulin with dextrose rapidly shifts potassium intracellularly, and hemodialysis removes potassium from the body.
Immediate medical management is required to prevent fatal cardiac dysrhythmias.

Key Concept

The priority management of severe hyperkalemia includes myocardial stabilization (calcium gluconate), intracellular potassium shifting (insulin and dextrose), and potassium elimination (hemodialysis), while recognizing respiratory compensation for metabolic acidosis.
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Physiological Adaptation

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