A practical nurse is caring for a client who is receiving continuous nasogastric (NG) tube suctioning for a mechanical bowel obstruction. During morning rounds, the client reports severe leg cramps and a fluttering sensation in the chest. The nurse assesses a blood pressure of mm Hg and an irregular heart rate of beats per minute. The most recent basic metabolic panel reveals a serum potassium level of mEq/L ( mmol/L). Which of the following actions should the nurse take first?
- ADocument the laboratory values in the electronic health record and plan to reassess the vital signs in one hour.
- BReassure the client that a fast heart rate is an expected physiological response to gastrointestinal discomfort.
- Notify the registered nurse immediately regarding the client's assessment findings and laboratory results.Answer
- DInstruct the assistive personnel (AP) to assess the client's telemetry strip to determine the rhythm.
Answer
The correct action is to notify the registered nurse immediately regarding the client's assessment findings and laboratory results.
Continuous nasogastric suctioning places the client at significant risk for electrolyte depletion, particularly hypokalemia. A serum potassium level of mEq/L is critically low (normal range is to mEq/L). The presence of severe leg cramps, palpitations, and an irregular heart rate indicates symptomatic hypokalemia, which can rapidly progress to life-threatening cardiac dysrhythmias. Recognizing these risk factors and immediately escalating the critical findings to the registered nurse is the priority action for the practical nurse to ensure prompt medical intervention.
Step-by-Step Solution
Key Concept
Identifying and escalating critical laboratory values and symptomatic complications (Reduction of Risk Potential).
Estimated Time:1m 15s