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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for a 74-year-old client who has been receiving continuous nasogastric (NG) tube suctioning for the past 48 hours due to a small bowel obstruction. Which of the following assessment findings indicate a potential complication and should be reported immediately to the registered nurse (RN)? Select all that apply.

  1. Apical pulse of 112 beats/min with thready peripheral pulsesAnswer
  2. New onset of agitation and disorientation to time and placeAnswer
  3. Client reports of severe leg cramps and generalized muscle weaknessAnswer
  4. D
    Hypoactive bowel sounds auscultated in all four abdominal quadrants
  5. E
    Urine output of 150 mL collected in the indwelling catheter over the past 4 hours
  6. F
    Capillary refill time of 2 seconds in the bilateral upper extremities

Answer

The abnormal findings that indicate potential complications and require immediate reporting are the apical pulse of 112 beats/min with thready pulses, the new onset of agitation and disorientation, and the reports of severe leg cramps with muscle weakness.
Continuous nasogastric suctioning rapidly depletes the body of fluids and electrolytes, particularly potassium. An apical pulse of 112 beats/min with thready pulses directly points to hypovolemia and impending shock. New-onset agitation and disorientation indicate diminished cerebral perfusion or a profound electrolyte disturbance, requiring emergent evaluation. Severe leg cramps and generalized muscle weakness are classic, immediate indicators of symptomatic hypokalemia. These acute physiological shifts must be reported to the RN for timely intervention.

Step-by-Step Solution

1
Analyze the client's current treatments and associated risks.
The client is undergoing continuous NG tube suctioning, which removes significant amounts of fluid, stomach acid, and electrolytes (especially potassium).
Identifying the therapy's physiological impact helps anticipate specific complications like fluid volume deficit, hypokalemia, and metabolic alkalosis.
2
Evaluate each assessment finding against normal limits and expected disease manifestations.
Tachycardia/thready pulses, acute confusion, and muscle cramping are abnormal and indicate deterioration. Hypoactive bowel sounds, 150 mL urine output over 4 hours, and a 2-second capillary refill are expected or normal findings.
Differentiating between expected findings of a bowel obstruction and acute signs of systemic instability is essential for safe prioritization.
3
Select the findings that reflect physiological instability.
The circulatory, neurological, and electrolyte-related abnormalities are identified as the priority complications to report.
Acute changes affecting ABCs (circulation/perfusion) and severe electrolyte shifts fall outside the PN scope of independent management and require RN intervention.

Key Concept

Recognizing systemic complications of fluid and electrolyte depletion
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Topics

Physiological Adaptation

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