# A nurse is caring for a client with stage 5 chronic kidney disease (CKD) who has developed hyperkalemia. Which nursing intervention should the nurse implement first?

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## 문제

A nurse is caring for a client with stage 5 chronic kidney disease (CKD) who has developed hyperkalemia. Which nursing intervention should the nurse implement first?

The nurse must prioritize interventions for a CKD patient with dangerous hyperkalemia to prevent cardiac complications.

## 보기

1. Administer sodium polystyrene sulfonate (Kayexalate) as ordered
2. Prepare the client for emergency hemodialysis
3. Restrict dietary potassium intake to less than 2 grams per day
4. Obtain a 12-lead electrocardiogram (ECG) immediately **✔ 정답**

**정답: 4**

## 해설

For severe hyperkalemia (K+ 6.8 mEq/L), the priority is to obtain an immediate ECG to assess for life-threatening cardiac dysrhythmias, as hyperkalemia can cause fatal complications. Other interventions like Kayexalate or hemodialysis are important but follow cardiac assessment.

## 심화 해설

Understanding the Priority: Safety and the Nursing Process

In a client with stage 5 chronic kidney disease (CKD), the kidneys have lost nearly all ability to excrete potassium, creating a constant risk for hyperkalemia. When hyperkalemia is identified, the immediate threat is not the elevated lab value itself, but the potential for life-threatening cardiac conduction disturbances. The nursing process dictates that assessment must come before intervention. Before administering any medication, preparing for dialysis, or implementing dietary teaching, the nurse must first determine the physiological impact of the high potassium level on the myocardium. A 12-lead electrocardiogram (ECG) provides this critical, real-time assessment data.

Why the ECG is the First Priority

Hyperkalemia depolarizes cardiac cell membranes, which slows conduction and alters the action potential. This can manifest on the ECG in a typically progressive, but not always predictable, manner. The earliest sign may be peaked T-waves, which can deteriorate into a widened QRS complex, and eventually into a sine-wave pattern and cardiac arrest. However, the provided evidence underscores a crucial clinical point: the absence of ECG changes does not rule out severe hyperkalemia, but the presence of certain patterns demands immediate action. The case described by Tahir et al. [2] involved a patient with a serum potassium of 8.7 mmol/L who presented with no ECG abnormalities. This demonstrates that a "normal" ECG provides a false sense of security only if it is not obtained; you must first look to know the rhythm status. Conversely, the cases by Achuta et al. [1] and Abdi et al. [4] show the other end of the spectrum, where hyperkalemia in missed-dialysis patients triggered BRASH syndrome and complete atrioventricular (AV) block with a ventricular escape rhythm of only 15-20 beats per minute. These rhythm findings directly dictate the next steps in management, such as the urgent administration of calcium gluconate to stabilize the cardiac membrane or emergency pacing. Without the ECG, the nurse is intervening blindly.

Analyzing the Other Options in the Context of Priority

- Administer sodium polystyrene sulfonate (Kayexalate) as ordered: This is an intervention to lower total body potassium by exchanging sodium for potassium in the gut. Its action is slow, taking hours to have an effect. It does nothing to antagonize the immediate cardiotoxic effects of potassium that is already circulating. This is an appropriate long-term management strategy but is not the first action for an acutely dangerous level .

- Prepare the client for emergency hemodialysis: Hemodialysis is the most effective method for removing potassium from the body and is a definitive treatment, especially in anuric stage 5 CKD patients who have missed dialysis, a classic trigger for BRASH syndrome [1]. However, preparing for dialysis is a process that takes time. The immediate priority is to assess cardiac stability and initiate membrane-stabilizing therapies if the ECG is abnormal. Dialysis preparation follows the initial assessment and emergency measures.

- Restrict dietary potassium intake to less than 2 grams per day: Dietary education is a crucial, long-term preventive strategy for managing chronic hyperkalemia in CKD, particularly to allow for continued use of renin-angiotensin-aldosterone system inhibitors (RAASi) . However, dietary restriction has no role in the acute management of a dangerously high potassium level. It is an inappropriate and ineffective first action when the client is at immediate risk for a fatal arrhythmia.

The correct sequence begins with obtaining the 12-lead ECG to assess for cardiotoxic effects. If the ECG shows signs of hyperkalemia (e.g., peaked T-waves, loss of P-waves, widened QRS), the nurse would then anticipate an order for intravenous calcium to stabilize the myocardium, followed by therapies to shift potassium intracellularly (e.g., insulin and glucose) and finally to remove potassium from the body (e.g., dialysis or a potassium binder) [1,4].References (research sources)

- [1]Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome Triggered by Missed Dialysis: A Case Report.Case reportAchuta KM, Vedantam V, Kommineni SK, Vedantam N, Venisha KS. (2025) · DOI: 10.7759/cureus.83713

- [2]Diagnostic Overlap Between Uremia and Severe Hyperkalemia in Chronic Kidney Disease: Emphasizing Laboratory-Guided Urgency Despite Absent EKG Changes.Research articleTahir MH, Tahir F, Tahir MM, Imran A, Asghar S. (2026) · DOI: 10.7759/cureus.107246

- [4]Complete Atrioventricular Block Due to Severe Hyperkalemia in a Hemodialysis Patient: Successful Management with Temporary Transvenous Pacing.Research articleAbdi AE, Arın CB, Abdi IA, Ahmed SA, Dahir OF, Aden AS, Hassan MO. (2026) · DOI: 10.2147/imcrj.s596948

## 임상 시나리오

Hyperkalemia in CKD: ECG FirstPrioritize assessment to identify cardiac threat before treatment
In stage 5 CKD, always obtain a 12-lead ECG immediately when hyperkalemia is identified. The primary threat is cardiac conduction disturbance, not the lab value itself.

Look for progressive ECG changes: peaked T-waves are often the earliest sign, which can advance to a widened QRS complex and a sine-wave pattern before cardiac arrest.

CautionA normal ECG does not rule out severe hyperkalemia. A patient can have a potassium level as high as 8.7 mmol/L with no ECG changes. Treat the patient based on the overall clinical picture, not just the tracing.

## 핵심 개념

- **Hyperkalemia** — An elevated serum potassium level that alters cardiac cell resting membrane potentials, increasing the risk of lethal arrhythmias such as ventricular fibrillation or asystole.
- **12-lead Electrocardiogram (ECG)** — A non-invasive diagnostic test that records the heart's electrical activity, used to detect cardiotoxic changes from hyperkalemia like peaked T-waves, loss of P-waves, and widened QRS complexes.
- **Chronic Kidney Disease (CKD) Stage 5** — End-stage renal disease with a glomerular filtration rate of less than 15 mL/min, characterized by the kidneys' inability to effectively excrete potassium, predisposing to hyperkalemia.
- **Sodium Polystyrene Sulfonate (Kayexalate)** — A cation-exchange resin administered orally or rectally to remove potassium from the body through the gastrointestinal tract, with a slow onset of action.

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