After noting QRS interval has lengthened from 0.08 to 0.16 and T wave is peaked in a client with acute kidney injury (AKI) which action should the nurse take first?

Notify the client's health care provider.

Look at the client's current blood urea nitrogen (BUN) and creatinine levels.

Document the QRS interval.

Check the chart for the most recent blood potassium level.

Answer and Explanation

The Correct Answer is D

A. Notify the client's health care provider: Contacting the provider will be necessary, but the nurse must first verify the potassium level because the ECG changes—widened QRS and peaked T waves—strongly suggest life-threatening hyperkalemia. Having the value ready allows immediate, precise communication and intervention.

B. Look at the client's current blood urea nitrogen (BUN) and creatinine levels: These levels confirm AKI severity but do not directly explain the dangerous conduction changes. Hyperkalemia poses an immediate risk of cardiac arrest, so potassium assessment takes priority for rapid correction.

C. Document the QRS interval: Documentation is routine but not urgent when ECG changes indicate an unstable electrolyte imbalance. Delaying assessment of potassium prolongs exposure to a potentially fatal arrhythmia and does not address the underlying cause.

D. Check the chart for the most recent blood potassium level: Peaked T waves and a widened QRS are hallmark findings of severe hyperkalemia. Verifying the potassium level is the most immediate step because it confirms the cause and guides emergent therapy such as calcium gluconate, insulin, or dialysis.

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Correct Answer is A

Explanation

A. Ventricular fibrillation and pulseless ventricular tachycardia: Both of these rhythms are considered shockable because they result in no effective cardiac output and can rapidly lead to death. Defibrillation delivers an unsynchronized electrical shock to depolarize the myocardium and restore a perfusing rhythm.

B. Ventricular fibrillation and pulseless electrical activity: Pulseless electrical activity is not a shockable rhythm. It involves organized electrical activity without mechanical cardiac output, so defibrillation is ineffective. Treatment focuses on CPR and addressing the underlying cause rather than delivering a shock.

C. Ventricular fibrillation and asystole: Asystole represents a flatline with no electrical or mechanical activity and is not shockable. Defibrillation will not restart cardiac activity; instead, CPR and pharmacologic interventions are prioritized. Only ventricular fibrillation in this pair is shockable.

D. Pulseless ventricular tachycardia and atrial fibrillation: Pulseless ventricular tachycardia is shockable, but atrial fibrillation is not typically treated with emergent defibrillation unless the patient is unstable and requires synchronized cardioversion. Atrial fibrillation is generally managed with rate or rhythm control, not immediate defibrillation.

A. hypotension, high central venous pressure and cardiac dysrhythmias. B. dyspnea, pain and normal movement of the chest wall. C. respiratory distress and paradoxical movement of the chest wall. D. cyanosis, air hunger, agitation and tracheal deviation to the side opposite the injury.

Correct Answer is C

Explanation

A. hypotension, high central venous pressure and cardiac dysrhythmias: These findings are more typical of cardiac tamponade or severe cardiac injury rather than flail chest, which primarily affects ventilation.

B. dyspnea, pain and normal movement of the chest wall: While dyspnea and pain are present in flail chest, normal chest wall movement would not be expected. The hallmark is paradoxical movement of the fractured segment during respiration.

C. respiratory distress and paradoxical movement of the chest wall: Flail chest occurs when multiple adjacent ribs are fractured in more than one place, creating a free-floating segment. This segment moves opposite to the rest of the chest during breathing (inward on inspiration, outward on expiration), causing impaired ventilation and respiratory distress.

D. cyanosis, air hunger, agitation and tracheal deviation to the side opposite the injury: Tracheal deviation is indicative of tension pneumothorax, not flail chest. While hypoxia may cause cyanosis and agitation, tracheal deviation is not a typical finding in flail chest.

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After noting QRS interval has lengthened from 0.08 to 0.16 and T wave is peaked in a client with acute kidney injury (AKI) which action should the nurse take first?

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