# A client with ESRD has K+ 7.2 with peaked T waves on ECG. Which is the priority medication?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391824&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A client with ESRD has K+ 7.2 with peaked T waves on ECG. Which is the priority medication?

## Option

1. Insulin without dextrose
2. Oral KCl
3. IV calcium gluconate to stabilize the cardiac membrane, followed by insulin + dextrose and beta-2 agonist to shift K intracellularly, then K-removal therapy (kayexalate/patiromer/sodium zirconium or dialysis) **✔ Correct answer**
4. Spironolactone

**Correct answer: 3**

## Explanation

Correct (2): Severe hyperkalemia with ECG changes — first IV calcium gluconate to stabilize cardiac membrane (rapid, no K removal). Then K shift: insulin + dextrose, beta-2 (albuterol), sodium bicarbonate if acidotic. Then K removal: sodium polystyrene sulfonate/patiromer/sodium zirconium or dialysis. (1) Hypoglycemia. (3,4) Worsen.

## In-depth explanation

Memory Tip Hyperkalemia ladder = "C BIG K Drop" — Calcium, Beta-2, Insulin/dex, Glucose, Kayexalate, Dialysis. Calcium does NOT lower K but protects heart.

## Clinical scenario

Scenario 65-year-old male ESRD missed HD. K+ 7.2 mEq/L·peaked T waves·widening QRS.

## Key concepts

- **Calcium gluconate** — Membrane stabilizer in hyperkalemia; does not lower K.
- **Insulin shift** — Drives K into cells; always give with dextrose to prevent hypoglycemia.
- **Hyperkalemia binders** — Sodium polystyrene sulfonate (kayexalate), patiromer, sodium zirconium cyclosilicate.

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