# A 59-year-old client with end-stage kidney disease on hemodialysis missed the last scheduled session 3 days ago and reports weakness and palpitations. Serum potassium is 7.0 mEq/L (5.4 mEq/L one week ago), calcium 9.0 mg/dL, magnesium 2.1 mg/dL, and troponin within normal limits. The cardiac monitor shows tall peaked T waves and a QRS duration that widened from 0.10 to 0.14 seconds over 30 minutes. Blood pressure is 146/88 mm Hg. The client has no chest pain. Prescriptions include IV calcium gluconate, IV regular insulin with dextrose, sodium zirconium cyclosilicate by mouth, and urgent hemodialysis. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617412&lang=en  
> language: en  
> subject: Medication Administration  
> category: PPT

## Question

A 59-year-old client with end-stage kidney disease on hemodialysis missed the last scheduled session 3 days ago and reports weakness and palpitations. Serum potassium is 7.0 mEq/L (5.4 mEq/L one week ago), calcium 9.0 mg/dL, magnesium 2.1 mg/dL, and troponin within normal limits. The cardiac monitor shows tall peaked T waves and a QRS duration that widened from 0.10 to 0.14 seconds over 30 minutes. Blood pressure is 146/88 mm Hg. The client has no chest pain. Prescriptions include IV calcium gluconate, IV regular insulin with dextrose, sodium zirconium cyclosilicate by mouth, and urgent hemodialysis. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Hypocalcemia
Acute myocardial infarction
Severe hyperkalemia
Hypermagnesemia

Actions to take

Select 2
Give sodium zirconium cyclosilicate as the first treatment
Administer prescribed IV calcium gluconate
Administer prescribed sublingual nitroglycerin
Administer prescribed IV magnesium sulfate
Give prescribed IV regular insulin with dextrose

Parameters to monitor

Select 2
Serial serum troponin level
Serum potassium level
Serum magnesium level
QRS duration on the ECG
Serum sodium level

## Explanation

Potassium of 7.0 mEq/L with peaked T waves and a widening QRS is a cardiac emergency. IV calcium gluconate stabilizes the myocardium within minutes, and IV insulin with dextrose shifts potassium into cells; the binder and dialysis remove potassium but act too slowly to be first. Serum potassium and QRS duration show whether treatment is working. Normal calcium, magnesium, and troponin exclude the differentials.

## In-depth explanation

Quick answer
Severe hyperkalemia with ECG changes; give prescribed IV calcium gluconate and IV regular insulin with dextrose, then monitor serum potassium and QRS duration.

Why this is correct
A widening QRS shows potassium is already affecting conduction and can progress to ventricular arrhythmia or asystole. Calcium does not lower potassium but raises the threshold for depolarization and protects the heart; insulin drives potassium into cells within about 15 to 30 minutes. Removal therapies follow once the heart is protected.

Easy analogy or mental picture
Picture a flooded engine room: first put up a shield (calcium) so sparks cannot ignite, then pump water into side tanks (insulin), and finally drain the ship (binder and dialysis).

Memory hook
Shield, shift, then shed: calcium, insulin with glucose, then binder or dialysis.

NCLEX decision rule
When hyperkalemia changes the ECG, protect the heart and shift potassium before choosing slower removal therapies, and monitor both the level and the ECG.

Why the other choices are wrong
A potassium binder is correct but works over hours, so giving it first delays life-saving treatment. Nitroglycerin and a troponin trend target myocardial infarction, which normal troponin and no chest pain make unlikely despite peaked T waves. Hypocalcemia prolongs the QT interval, and calcium here is normal. Magnesium sulfate treats torsades de pointes and does not lower potassium, and the magnesium level is normal. Serum sodium does not track this emergency.

References
1MedlinePlus — High potassium levelSevere hyperkalemia causes dangerous heart rhythm changes and needs emergency treatment.
2DailyMed — Sodium zirconium cyclosilicate labelingThe label states it should not be used as emergency treatment for life-threatening hyperkalemia because of delayed onset.

## Clinical scenario

Scenario
After a missed dialysis session, a client has potassium 7.0 mEq/L with peaked T waves and a widening QRS; calcium, magnesium, and troponin are normal.

## Key concepts

- **Peaked T waves** — Tall, narrow T waves that are an early ECG sign of hyperkalemia.
- **Membrane stabilization** — The protective effect of IV calcium that reduces cardiac excitability without lowering potassium.
- **Sodium zirconium cyclosilicate** — An oral potassium binder that removes potassium through the gut over hours.

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