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Difficulty: MediumPhysiological Adaptation

A client with a mechanical bowel obstruction has been receiving continuous gastric decompression via a nasogastric (NG) tube for three days. During morning data collection, the client reports generalized muscle weakness, severe calf cramps, and a "skipping" sensation in the chest. Which action should the practical nurse take first?

  1. Obtain a full set of vital signs including an apical pulse and immediately notify the registered nurse.Answer
  2. B
    Apply warm compresses to the client's lower extremities to relieve the muscle cramping.
  3. C
    Clamp the nasogastric tube to prevent further depletion of stomach acids and fluids.
  4. D
    Review the most recent laboratory results and plan to report the findings at shift change.

Answer

The practical nurse should obtain a full set of vital signs including an apical pulse and immediately notify the registered nurse.
Prolonged nasogastric suctioning places a client at high risk for hypokalemia and metabolic alkalosis due to the excessive loss of gastric fluids. The client's symptoms of muscle weakness, severe calf cramps, and a "skipping" heartbeat are classic manifestations of hypokalemia, which can lead to life-threatening cardiac dysrhythmias. The practical nurse must immediately obtain baseline cardiovascular data, specifically an apical pulse, and urgently notify the registered nurse so that a 12-lead ECG and potassium replacement can be prescribed.

Step-by-Step Solution

1
Analyze the client's symptoms and history.
The client has a history of prolonged NG tube suctioning and is presenting with muscle weakness, leg cramps, and palpitations.
Prolonged gastric suctioning removes potassium-rich fluids from the stomach, placing the client at high risk for severe hypokalemia.
2
Prioritize the physiological cues.
The "skipping" heartbeat (palpitations) combined with muscle weakness indicates a potential cardiac dysrhythmia due to electrolyte imbalance.
According to the ABCs (Airway, Breathing, Circulation), a potential cardiac issue takes precedence over muscle discomfort.
3
Determine the appropriate action within the practical nursing scope of practice.
The nurse must collect focused immediate data (vital signs and apical pulse) and report the critical change to the RN.
The RN and healthcare provider need baseline hemodynamic data to initiate emergency electrolyte replacement protocols.

Key Concept

Recognizing and prioritizing complications of fluid and electrolyte imbalances
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Topics

Physiological Adaptation

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