# A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. The nurse reviews the ECG and notes peaked T waves. For each group, select all responses that apply.

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=620039&lang=en  
> language: en  
> subject: Postsurgical Complications  
> category: ROR

## Question

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. The nurse reviews the ECG and notes peaked T waves. For each group, select all responses that apply.

Immediate nursing actions

Notify the healthcare provider

Place the client on a cardiac monitor

Administer oral potassium chloride

Encourage a banana and orange juice

Anticipated medical orders

Intravenous calcium gluconate

Intravenous insulin and dextrose

Oral spironolactone

Intravenous potassium chloride

## Explanation

Hyperkalemia with ECG changes is a medical emergency. The nurse must notify the provider and monitor cardiac rhythm for dysrhythmias. Administering potassium or high-potassium foods would worsen the condition. Anticipated orders include IV calcium gluconate to stabilize cardiac membranes and IV insulin with dextrose to shift potassium into cells. Spironolactone, a potassium-sparing diuretic, would increase potassium, and IV potassium is contraindicated.

## In-depth explanation

Quick answer
Hyperkalemia with ECG changes is a medical emergency. The nurse must notify the provider and monitor cardiac rhythm for dysrhythmias. Administering potassium or high-potassium foods would worsen the condition. Anticipated orders include IV calcium gluconate to stabilize cardiac membranes and IV insulin with dextrose to shift potassium into cells. Spironolactone, a potassium-sparing diuretic, would increase potassium, and IV potassium is contraindicated.
Key cues
Use the client-specific assessment findings and timing in the scenario rather than a memorized diagnosis label.
Clinical reasoning
Connect the relevant cues to the safest nursing interpretation and action for this exact care setting.
Why the alternatives do not fit
The distractors are plausible in another context but are unsupported, mistimed, lower priority, or incomplete for the findings presented.
Priority and safety
Address immediate threats first, stay within nursing scope, and reassess the client after the selected intervention.
Takeaway
For hyperkalemia cues and response, select responses that are both clinically supported and appropriate at this point in care.
**Sources**
- FDA Drug Safety Information

## Clinical scenario

A client with chronic kidney disease has a serum potassium of 6.8 mEq/L. The nurse reviews the ECG and notes peaked T waves. For each group, select all responses that apply.

## Key concepts

- **peaked T waves** — Tall, narrow T waves on ECG, an early sign of hyperkalemia.
- **calcium gluconate** — IV medication that antagonizes cardiac effects of hyperkalemia without lowering serum potassium.
- **insulin and dextrose** — Combination that shifts potassium from extracellular to intracellular space, temporarily lowering serum potassium.

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