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Question

Difficulty: HardReduction of Risk Potential

An adult client with a mechanical small bowel obstruction has been receiving continuous nasogastric (NG) decompression for the past 48 hours. The nurse evaluates the client's morning laboratory and arterial blood gas (ABG) results:

Potassium: 2.6 mEq/L (2.6 mmol/L)
pH: 7.53
PaCO2: 49 mm Hg
HCO3-: 35 mEq/L
PaO2: 88 mm Hg

The client is lethargic with a respiratory rate of 10 breaths per minute and shallow chest excursion. To prevent immediate physiological decompensation, which intervention should the nurse prioritize?

  1. Initiate continuous cardiac monitoring and request a prescription for intravenous potassium replacement.Answer
  2. B
    Instruct the client to take deep, forceful breaths to correct the elevated carbon dioxide level.
  3. C
    Place the client in a flat, supine position to optimize venous return and correct the lethargy.
  4. D
    Prepare emergency airway equipment for immediate endotracheal intubation due to impending respiratory failure.

Answer

Initiate continuous cardiac monitoring and request a prescription for intravenous potassium replacement.
The client is experiencing metabolic alkalosis with compensatory respiratory acidosis (hypoventilation) and severe hypokalemia due to prolonged gastric suctioning. Hypokalemia (2.6 mEq/L) places the client at imminent risk for life-threatening cardiac dysrhythmias. Initiating cardiac monitoring and replacing potassium addresses the most critical physiological threat, thereby reducing the risk of a fatal complication.

Step-by-Step Solution

1
Analyze the ABG results.
pH is alkalotic (7.53), HCO3- is high (35 mEq/L), indicating metabolic alkalosis. PaCO2 is high (49 mm Hg), indicating partial respiratory compensation.
Understanding the acid-base imbalance directs the nurse to the physiological cause rather than misinterpreting the abnormal respiratory rate as primary lung failure.
2
Analyze the laboratory values in the context of the client's treatment.
Potassium is critically low at 2.6 mEq/L. Prolonged NG suction removes hydrochloric acid and potassium from the stomach, causing both the metabolic alkalosis and the hypokalemia.
Identifying the severe hypokalemia reveals the most imminent risk to the client's life.
3
Evaluate the respiratory assessment (lethargy, RR 10).
The hypoventilation is a deliberate compensatory mechanism by the body to retain acid (CO2) and balance the high blood pH.
Differentiating between compensatory hypoventilation and true respiratory failure prevents the nurse from implementing harmful interventions like forcing deep breaths.
4
Determine the priority intervention.
Cardiac monitoring and potassium replacement take absolute precedence to prevent fatal dysrhythmias.
Risk reduction requires addressing the most immediately lethal threat first, which in this scenario is the profound hypokalemia.

Key Concept

Complications of Gastric Decompression and Hypokalemia
Estimated Time:2m 0s
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Topics

Reduction of Risk Potential

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