A client has a potassium level of 6.9 mEq/L and a widened QRS complex. For each finding or intervention, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
Severe hyperkalemia with QRS widening threatens lethal dysrhythmia. Continuous ECG monitoring and prescribed IV calcium protect the myocardium; insulin with glucose shifts potassium intracellularly. Repeat potassium, ECG, and glucose checks identify response, hypoglycemia, or rebound while definitive potassium removal is arranged.
Quick answer QRS widening is an immediate danger cue. Give prescribed IV calcium for cardiac membrane stabilization, use insulin with glucose to shift potassium, monitor glucose, and reassess potassium and ECG while arranging potassium removal.
Why this is correct Potassium 6.9 mEq/L with an ECG change is severe hyperkalemia with imminent dysrhythmia risk. Calcium protects the heart but does not lower serum potassium, so shifting and removal strategies are also required.
Easy analogy or mental picture Calcium is a temporary shield around the heart; insulin moves potassium into cells, and removal therapy empties excess potassium from the body.
Memory hook Protect the heart, shift the potassium, remove it, then recheck.
NCLEX decision rule ECG changes move hyperkalemia into the emergency pathway. Monitor continuously, treat immediately as prescribed, and schedule repeat potassium and glucose testing because rebound hyperkalemia and treatment-related hypoglycemia can occur.
Why the other choices are wrong Potassium supplementation directly worsens the problem. Waiting for an outpatient recheck ignores a current electrical instability and risks cardiac arrest.
Source
1UK Kidney Association Hyperkalaemia Guideline
22026 NCLEX-RN Test Plan
The client is on continuous cardiac monitoring with IV access. The nurse implements the prescribed emergency hyperkalemia protocol and reassesses the ECG, potassium, glucose, and response to therapy.
Severe hyperkalemia — A dangerously elevated serum potassium level that can disrupt cardiac conduction and cause fatal dysrhythmias.
Cardiac membrane stabilization — Temporary reduction of myocardial excitability with IV calcium while potassium-lowering treatment proceeds.
Intracellular potassium shift — Temporary movement of potassium from extracellular fluid into cells, such as with insulin and glucose.