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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is organizing care for a group of clients on a medical-surgical unit. Which of the following nursing actions demonstrate the correct application of risk reduction principles? (Select all that apply)

  1. Escalating a post-liver biopsy client's blood pressure of 94/58 mmHg and heart rate of 112 beats/min to the registered nurse (RN)Answer
  2. B
    Delaying the report of a client's serum potassium level of 2.6 mEq/L until afternoon rounds because the client is currently asymptomatic
  3. Verifying nasogastric tube placement by checking the pH of aspirated gastric contents prior to initiating a scheduled enteral feedingAnswer
  4. D
    Prioritizing the documentation of routine morning assessments over evaluating a client who reports a sudden onset of chest tightness
  5. Instructing a client who is recovering from an open abdominal surgery to splint the incision with a pillow while coughingAnswer

Answer

The correct actions include escalating borderline vital signs that suggest shock, verifying nasogastric tube placement via pH testing, and instructing a postoperative client to splint their incision.
To reduce the risk of potential complications, the practical nurse must recognize early signs of clinical deterioration and implement evidence-based preventative measures. A borderline low blood pressure with tachycardia after an invasive biopsy suggests early hypovolemic shock and requires immediate escalation. Verifying gastric pH prevents the severe complication of pulmonary aspiration during tube feeding. Splinting an abdominal incision supports the wound and reduces the risk of dehiscence during coughing. These actions directly prioritize client safety.

Step-by-Step Solution

1
Evaluate each nursing action against the principles of risk reduction and safe scope of practice.
Identify which actions proactively prevent complications or appropriately address potentially life-threatening changes.
Risk reduction requires the practical nurse to combine preventative care with the immediate recognition of instability.
2
Analyze the clinical data provided in the options.
A blood pressure of 94/58 mmHg with a heart rate of 112 beats/min indicates potential bleeding. A potassium level of 2.6 mEq/L is critically low. Chest tightness is a potential cardiopulmonary emergency.
Recognizing abnormal parameters is the critical first step before deciding on the appropriate risk-reduction action.
3
Select the actions that correctly mitigate risk.
Escalating the abnormal vital signs, checking gastric pH prior to feeding, and splinting the abdominal incision are correct risk-reduction actions.
These actions directly align with patient safety guidelines and prioritize the client's physiological stability.

Key Concept

Early recognition of complications and implementation of preventative nursing measures.
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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