# A patient with stage 5 chronic kidney disease has missed two scheduled hemodialysis sessions. Serum potassium is 7.4 mEq/L. The cardiac monitor shows peaked T waves and a widening QRS complex. Which orders should the nurse anticipate and carry out promptly? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=372845&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

A patient with stage 5 chronic kidney disease has missed two scheduled hemodialysis sessions. Serum potassium is 7.4 mEq/L. The cardiac monitor shows peaked T waves and a widening QRS complex. Which orders should the nurse anticipate and carry out promptly? Select all that apply.

1

Notify nephrology and prepare the patient for emergent hemodialysis, the only definitive removal therapy in dialysis-dependent CKD.

2

IV regular insulin 10 units with 25 g of dextrose 50 percent to drive potassium intracellularly, then monitor capillary glucose every 15 to 30 minutes for at least one hour.

3

Administer sodium polystyrene sulfonate 30 g orally to bind potassium and facilitate its removal through the gastrointestinal tract.

4

IV calcium gluconate 1 to 2 g infused over 5 to 10 minutes for cardiac membrane stabilization while continuing cardiac monitoring.

5

Nebulized albuterol 10 to 20 mg as adjunctive intracellular shift therapy, anticipating tachycardia and tremor as expected effects.

## Explanation

Severe hyperkalemia with ECG changes is a life-threatening emergency. The correct bundle includes: (1) Notify nephrology and prepare for emergent hemodialysis, as dialysis is the only definitive potassium removal in dialysis-dependent CKD. (2) IV regular insulin 10 units with 25 g dextrose 50% to shift potassium intracellularly; monitor glucose afterward. (4) IV calcium gluconate 1–2 g over 5–10 min for cardiac membrane stabilization without lowering potassium. (5) Nebulized albuterol 10–20 mg as adjunctive intracellular shift therapy; tachycardia and tremor are expected. Option 3, sodium polystyrene sulfonate (SPS), is incorrect for acute severe hyperkalemia because its onset is slow (hours) and it carries a risk of intestinal necrosis; it is not a first-line emergency intervention.

## In-depth explanation

Hyperkalemia with ECG changes follows the SHIFT-AND-REMOVE logic: stabilize the membrane (calcium), shift K+ into cells (insulin/dextrose, albuterol, optionally bicarbonate if acidotic), then remove K+ from the body (dialysis is fastest in dialysis-dependent patients; SPS or patiromer take hours and are inappropriate as the only therapy here).

## Clinical scenario

**Stage 5 CKD patient** on chronic hemodialysis missed **two consecutive sessions**. Serum K+ is **7.4 mEq/L**. The monitor shows **peaked T waves with a widening QRS**. The patient is alert but anxious.

## Key concepts

- **Hyperkalemia** — Serum K+ greater than 5.0 mEq/L; severe at 6.5 or higher with ECG changes such as peaked T waves, widened QRS, or sine-wave pattern.
- **Calcium gluconate** — First drug given for hyperkalemia with ECG changes — stabilizes the cardiac membrane within minutes without lowering serum K+.
- **Insulin–dextrose shift** — Regular insulin 10 units IV with 25 g of D50 drives K+ intracellularly within 15 minutes; monitor glucose every 15 to 30 minutes for one or more hours.

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