A patient with acute kidney injury has a potassium level of 6.7 mmol/L and reports new muscle weakness. Which action should the nurse take first?
Correct answer: A. Place the patient on continuous cardiac monitoring
- A. Place the patient on continuous cardiac monitoring
- B. Offer a high-potassium snack to improve energy
- C. Encourage ambulation to assess functional strength
- D. Document the result and wait for the next ward round
Explanation
Severe hyperkalaemia can cause sudden, fatal cardiac dysrhythmias, even before other symptoms appear. Continuous cardiac monitoring is an immediate safety measure while the result is urgently escalated for treatment. High-potassium food and delay are unsafe.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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