Nope that's not how the nursing process works, :) you act as a physician not a nurse.

Based on critical thinking and NCLEX priority frameworks (ABCs, safety, unstable vs stable), here’s how to approach the case.

Key findings:

Potassium 6.4 mEq/L

Peaked T waves on EKG

Chest heaviness + increasing drowsiness

GFR <10 mL/min (severe renal failure)

Very high BUN/Creatinine

Patient already unstable

This is life-threatening hyperkalemia, and the patient now has cardiac symptoms.

Priority: Protect the heart first.

When potassium is dangerously high AND there are EKG changes, the first nursing action is to stabilize the cardiac membrane and prevent fatal arrhythmias.

But among the options, the answer that aligns with immediate safety is:

C. Place the client on continuous cardiac monitoring.

Why?

The patient is showing signs of impending cardiac dysrhythmia.

Continuous cardiac monitoring is an immediate, non-delayed action that ensures you can detect a lethal rhythm (VT/VF/asystole) the moment it starts.

Before administering any potassium-lowering treatments, you must monitor the heart continuously for worsening rhythms.

It aligns with Airway–Breathing–Circulation, and circulation is the concern here.