A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an intravenous (IV) infusion of lactated Ringer's at 100 mL/hour.
Which finding is most important for the nurse to report to the healthcare provider? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L).

Choice A rationale:

Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.

Choice B rationale:

Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.

Choice C rationale:

While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.

Choice D rationale:

Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.

Choice A rationale:

Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.

Choice B rationale:

Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.

Choice C rationale:

Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.

Choice D rationale:

Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.