Mark Klimek NCLEX-RN Yellow Book Practice Test

The first action to take when potassium levels are high, especially in the range of 5.4 to 5.9, is to hold potassium if it is being administered via IV. This is crucial because the administration of potassium can exacerbate the hyperkalemia, potentially leading to severe cardiac complications. Monitoring and managing potassium levels are vital, as even moderately elevated levels can significantly impact cardiac function.

Holding potassium helps prevent further increases in serum potassium levels, which is essential while awaiting further assessment and intervention from the healthcare team. Once the potassium administration is halted, further actions such as assessing the heart, calling the doctor, or preparing other therapeutic measures, like administering D5W with insulin, can be effectively initiated based on the patient's condition and the healthcare provider's orders.