In a patient with eGFR 28 mL/min/1.73 m2, potassium 5.9 mEq/L, bicarbonate 18 mEq/L, BUN 60 mg/dL, and creatinine 2.4 mg/dL, what is the most immediate nursing intervention?

• A. Initiate treatment for hyperkalemia (calcium gluconate IV to stabilize myocardium, insulin with glucose to shift K+ intracellularly, and consider beta-agonist) and prepare for possible dialysis; monitor EKG.
• B. Increase dietary potassium.
• C. Ignore potassium and monitor.
• D. Schedule dialysis in six months.

Answer: (A)

Controlling hyperkalemia and protecting the heart is the immediate priority in this scenario. The patient has advanced kidney disease with a high potassium level and metabolic acidosis, both of which raise the risk of dangerous arrhythmias. The first step is to stabilize the myocardium with IV calcium gluconate. This does not lower potassium, but it protects heart cells from the altered membrane excitability caused by hyperkalemia.

Next, shift potassium from the extracellular space into cells by giving insulin with glucose. This lowers serum potassium quickly, buying time to manage the underlying problem. A beta-adrenergic agonist (such as albuterol) can be added to help move potassium into cells as well. Throughout this, continuous ECG monitoring is essential to detect any evolving rhythm changes and to gauge response.

Definitive management may include preparing for dialysis, since removing potassium directly from the blood is the only way to restore long-term balance in someone with kidney failure. If potassium remains elevated despite initial measures or if there are signs of a hyperkalemic emergency, dialysis becomes urgent.

Increasing dietary potassium would worsen the situation, ignoring potassium is unsafe, and scheduling dialysis in six months would not address the immediate risk.