A client has been NPO after a colectomy with nasogastric (NG) suction in place. On assessment, the nurse finds the client reporting cramps in the calves. Which action by the nurse is most appropriate?
a. Document findings and notify the physician.
b. Stop suction and request that the laboratory draw arterial blood gases.
c. Prepare to administer lorazepam (Ativan).
d. Raise the siderails and notify the physician.
D
The client has a metabolic alkalosis probably caused by prolonged suctioning. The client also is experiencing tetany, caused by the accompanying hypocalcemia, and is at risk for seizures. The priority is to maintain the client's safety; this includes raising the siderails and then notifying the physician. Documentation is important but not as important as providing safety. The nurse would not stop the suction without an order. The client may need lorazepam if he or she has seizures, but this is not the first action the nurse would perform.
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ANS:
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