# Place the prescribed actions in priority order for a client with severe hyperkalemia and ECG changes.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396374&lang=en  
> language: en  
> subject: Medication Administration  
> category: PPT

## Question

Place the prescribed actions in priority order for a client with severe hyperkalemia and ECG changes.

Begin continuous cardiac monitoring, stay with the client, and activate the urgent response or notify the prescriber immediately.

Trend the ECG, potassium, glucose, renal status, and recurrence risk, and communicate the response to treatment.

Administer the prescribed IV calcium preparation to stabilize the myocardium according to the emergency protocol.

Initiate the prescribed potassium-removal plan, such as a diuretic, potassium binder, or urgent dialysis based on the cause and kidney function.

Administer prescribed insulin with glucose and any other ordered intracellular-shift therapy, then monitor glucose closely.

## Explanation

With severe hyperkalemia and ECG changes, monitor and escalate immediately, then give prescribed IV calcium to protect the heart. Intracellular-shift therapy lowers the circulating potassium temporarily, while removal therapy eliminates potassium from the body. Serial ECG, potassium, and glucose monitoring detect incomplete response, recurrence, and treatment-related hypoglycemia.

## In-depth explanation

Correct sequence
Monitor and escalate → protect the heart → shift potassium → remove potassium → reassess.

Why this is correct
ECG toxicity makes this a time-critical emergency. IV calcium can improve electrical instability but does not lower the potassium concentration. Insulin with glucose moves potassium into cells temporarily, so a removal strategy and continued monitoring are still required. Repeating a clearly plausible result must not delay myocardial protection.

NCLEX decision rule
Separate the treatment goals: calcium protects the myocardium, shift therapies buy time, removal therapies solve the potassium burden, and serial monitoring detects rebound and hypoglycemia.References
1UK Kidney Association hyperkalemia guideline2023 clinical practice guideline
2Resuscitation Council UK 2025 special-circumstances guideline

## Clinical scenario

Hyperkalemia emergency
A client with chronic kidney disease has potassium 6.8 mmol/L, peaked T waves, and QRS widening. The result fits the clinical context and IV access is present. Do not delay emergency treatment to repeat the laboratory test.

## Key concepts

- **Myocardial Stabilization** — Temporary reduction of cardiac membrane excitability from hyperkalemia without removing potassium from the body.
- **Intracellular Shift** — Temporary movement of potassium from extracellular fluid into cells.
- **Peaked T Waves** — An ECG finding associated with hyperkalemia.

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