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Difficulty: MediumReduction of Risk Potential

A client with a mechanical small bowel obstruction has been on low continuous nasogastric (NG) wall suction for the past 4848 hours. The client begins to report numbness and tingling around the mouth and muscle cramping in the calves. Morning arterial blood gas (ABG) results are: pH 7.517.51, PaCO 2_2 4343 mm Hg, HCO 3−_3^- 3232 mEq/L. To reduce the risk of a severe complication associated with these findings, which focused assessment should the nurse perform next?

  1. Analyze the client's electrocardiogram (ECG) rhythm strip for prominent U waves or ST depression.Answer
  2. B
    Evaluate the client's respiratory pattern for deep, rapid breaths with a fruity odor.
  3. C
    Assess the client's level of consciousness for progressive lethargy and confusion.
  4. D
    Auscultate the client's bowel sounds to determine the return of normal gastrointestinal motility.

Answer

Analyze the client's electrocardiogram (ECG) rhythm strip for prominent U waves or ST depression.
The correct answer addresses the most severe physiological threat stemming from the client's current status. The ABG indicates metabolic alkalosis, a direct result of gastric acid loss from NG suction. In metabolic alkalosis, potassium shifts into the cells, leading to hypokalemia. Simultaneously, calcium binds more readily to albumin, resulting in decreased ionized calcium, which causes the tetany (numbness, tingling, cramping) the client reports. The most life-threatening complication of hypokalemia is the development of cardiac dysrhythmias. The nurse must prioritize analyzing the ECG for classic signs of hypokalemia, such as prominent U waves and ST depression, to mitigate this severe risk.

Step-by-Step Solution

1
Interpret the provided arterial blood gas (ABG) values.
The pH of 7.517.51 indicates alkalosis, and the HCO 3−_3^- of 3232 mEq/L indicates a metabolic primary cause. The PaCO 2_2 is normal, indicating an uncompensated state.
Identifying the exact acid-base imbalance is the first step in anticipating the client's physiological complications.
2
Correlate the acid-base imbalance with the clinical scenario.
Prolonged nasogastric suction removes hydrochloric acid from the stomach, which is the direct cause of the metabolic alkalosis.
Understanding the etiology helps anticipate the associated secondary electrolyte shifts.
3
Identify the electrolyte derangements associated with metabolic alkalosis.
Metabolic alkalosis triggers an intracellular shift of potassium, causing hypokalemia. It also increases calcium binding to albumin, decreasing ionized calcium and causing tetany (manifested as numbness and cramping).
Electrolyte imbalances drive the most immediate and life-threatening complications.
4
Determine the highest-priority nursing assessment to reduce the risk of a severe complication.
Hypokalemia severely destabilizes cardiac conduction, risking lethal dysrhythmias. Assessing the ECG for hypokalemic indicators (U waves, ST depression) is the most critical intervention.
Cardiac dysrhythmias pose the most immediate threat to the client's life and require rapid identification.

Key Concept

Metabolic Alkalosis and Associated Electrolyte Imbalances
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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