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Difficulty: HardReduction of Risk Potential

A nurse is evaluating a 64-year-old client who is 12 hours postoperative following a massive bowel resection with the creation of a colostomy. The client is receiving continuous intravenous fluids and has a nasogastric (NG) tube connected to low intermittent wall suction. Which of the following assessment findings represent a high-risk physiological complication requiring the nurse's immediate intervention? Select all that apply.

  1. The client's radial pulse is 122 beats/min and thready, with a narrowing pulse pressure.Answer
  2. Arterial blood gas (ABG) results indicate a pH of 7.52, PaCO2 of 42 mm Hg, and HCO3- of 34 mEq/L.Answer
  3. The client exhibits a positive Trousseau's sign when blood pressure is being measured.Answer
  4. D
    Arterial blood gas (ABG) results indicating a PaO2 of 94 mm Hg and an SaO2 of 97% on room air.
  5. E
    Auscultation of the abdomen reveals absent bowel sounds in all four quadrants after 3 minutes of continuous listening.
  6. F
    The client is resting in a semi-Fowler's position with pillows placed under the knees to maintain slight flexion.

Answer

The findings requiring immediate intervention are the thready tachycardia with narrowing pulse pressure (indicating shock), the severe metabolic alkalosis on the ABG, and the positive Trousseau's sign (indicating hypocalcemia).
A thready heart rate of 122 beats/min with a narrowing pulse pressure indicates early hypovolemic shock, requiring immediate fluid resuscitation. The ABG reveals severe metabolic alkalosis (pH > 7.45, HCO3- > 26 mEq/L) directly caused by the continuous loss of gastric hydrochloric acid from the NG suction. Furthermore, metabolic alkalosis decreases ionized calcium levels in the blood, leading to acute hypocalcemia which manifests as neuromuscular excitability (a positive Trousseau's sign). All three of these findings represent severe physiological decompensation requiring immediate medical intervention.

Step-by-Step Solution

1
Analyze the clinical scenario
The client is 12 hours post-op from a massive bowel resection and has active NG suction.
Establishing the postoperative timeframe and current therapies helps predict potential complications versus normal findings.
2
Evaluate vital signs for signs of shock
Identified a thready heart rate of 122 beats/min and a narrowing pulse pressure as abnormal.
These are classic early indicators of hypovolemia or hemorrhage, which are high-risk complications after major abdominal surgery.
3
Interpret ABG values in the context of NG suction
Identified a pH of 7.52 and HCO3- of 34 mEq/L as uncompensated metabolic alkalosis.
Continuous low wall suction removes large amounts of hydrochloric acid from the stomach, causing alkalosis.
4
Connect metabolic alkalosis to electrolyte shifts
Identified the positive Trousseau's sign as a manifestation of hypocalcemia.
Alkalemia increases calcium binding to albumin, reducing ionized calcium and causing neuromuscular excitability.
5
Rule out expected postoperative findings and appropriate care
Ruled out the absent bowel sounds, normal PaO2, and semi-Fowler's position.
Absent bowel sounds are expected for 24-72 hours post-op, normal ABG oxygenation needs no intervention, and slight knee flexion reduces abdominal tension appropriately.

Key Concept

Recognition of life-threatening complications (hypovolemic shock, metabolic alkalosis, and acute hypocalcemia) following massive abdominal surgery and gastric suction.
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Reduction of Risk Potential

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