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Difficulty: MediumReduction of Risk Potential

An adult client presents to the emergency department reporting severe, intractable vomiting for the past four days. The client is lethargic and exhibits shallow respirations, bilateral calf cramping, and tingling around the mouth. An arterial blood gas (ABG) analysis reveals a pH of 7.55, a PaCO2 of 44 mm Hg, and an HCO3- of 36 mEq/L. To prevent the development of a life-threatening complication associated with these clinical findings, which intervention is the highest priority for the nurse to implement?

  1. Establish continuous electrocardiogram (ECG) monitoring and prepare for intravenous potassium replacement.Answer
  2. B
    Coach the client to breathe deeply into a paper bag to facilitate the retention of carbon dioxide.
  3. C
    Administer a prescribed intravenous bolus of sodium bicarbonate to correct the acid-base imbalance.
  4. D
    Place the client in a supine position with the legs elevated to treat suspected hypovolemic shock.

Answer

Establish continuous electrocardiogram (ECG) monitoring and prepare for intravenous potassium replacement.
The client's ABG results indicate metabolic alkalosis (pH > 7.45, HCO3- > 26 mEq/L) resulting from severe gastric acid loss due to prolonged vomiting. This condition causes an intracellular shift of potassium, leading to hypokalemia, which is evidenced by the client's calf cramping and paresthesia. Hypokalemia places the client at an immediate, life-threatening risk for cardiac dysrhythmias. Therefore, the highest priority action to reduce this risk is to initiate continuous cardiac telemetry and prepare for potassium replacement.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
The pH is 7.55 (alkalosis), PaCO2 is 44 mm Hg (normal range), and HCO3- is 36 mEq/L (high), which confirms uncompensated metabolic alkalosis.
Accurate interpretation of diagnostic data is required to identify the primary physiological disturbance.
2
Correlate the client's clinical symptoms with the underlying pathophysiology.
The history of prolonged vomiting explains the significant loss of gastric acid (hydrogen ions). The calf cramping and perioral tingling strongly suggest concurrent hypokalemia and hypocalcemia, which are common and dangerous complications of metabolic alkalosis due to intracellular fluid shifts.
Connecting observable symptoms to the acid-base imbalance helps identify the highest priority physiological risks.
3
Determine the highest priority intervention to reduce physiological risk.
Hypokalemia poses a severe, immediate risk for fatal cardiac dysrhythmias. Initiating continuous ECG monitoring and preparing for electrolyte replacement addresses this life-threatening potential.
In accordance with prioritization frameworks, interventions that prevent immediate circulatory collapse or fatal arrhythmias must take precedence.

Key Concept

Identifying complications of metabolic alkalosis and mitigating the risk of hypokalemia-induced cardiac dysrhythmias.
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Topics

Reduction of Risk Potential

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