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Difficulty: HardPharmacological Therapies

A practical nurse (PN) is evaluating clients on a medical-surgical unit prior to dispensing scheduled medications. Which of the following clinical scenarios require the PN to withhold the pharmacological therapy and immediately intervene by notifying the registered nurse (RN)? Select all that apply.

  1. A client prescribed oral warfarin for atrial fibrillation who has a recent International Normalized Ratio (INR) of 4.84.8.Answer
  2. B
    A client prescribed a daily potassium chloride supplement who has a morning serum potassium level of 4.2 mEq/L4.2 \text{ mEq/L} (4.2 mmol/L4.2 \text{ mmol/L}).
  3. A client prescribed oral metoprolol for hypertension who has a heart rate of 105 beats/minute105 \text{ beats/minute} and a blood pressure of 88/54 mm Hg88/54 \text{ mm Hg}.Answer
  4. A provider order directing the PN to administer a one-time intravenous (IV) push dose of bumetanide for a client experiencing fluid volume overload.Answer
  5. E
    A client scheduled for an intramuscular (IM) influenza vaccine who reports experiencing mild arm soreness after last year's dose.
  6. F
    A client with expressive aphasia scheduled for oral medications whose identity must be verified using a barcode scanner and wristband rather than verbal confirmation.

Answer

The correct scenarios requiring the PN to withhold therapy and notify the RN involve the client with a supratherapeutic INR of 4.8, the client with hypotension (blood pressure 88/54 mm Hg) prescribed a beta-blocker, and the order directing the PN to administer an IV push medication.
The PN must recognize situations that compromise client safety or fall outside their legal scope of practice. An INR of 4.8 is significantly elevated above the therapeutic target (typically 2.0-3.0), placing the client at high risk for spontaneous bleeding; the warfarin must be withheld. The client prescribed metoprolol is experiencing significant hypotension (88/54 mm Hg), and administering a beta-blocker could precipitate severe hemodynamic instability or shock. Finally, administering medications via the intravenous (IV) push route is universally outside the scope of practice for a PN, requiring the RN to take over the task.

Step-by-Step Solution

1
Analyze the client prescribed warfarin.
An INR of 4.8 is supratherapeutic (normal therapeutic range is typically 2.0-3.0 for most indications). Administering warfarin increases the risk of severe hemorrhage.
The PN must withhold the dose and notify the RN to prevent a critical bleeding event.
2
Evaluate the client prescribed metoprolol.
The client has a blood pressure of 88/54 mm Hg, indicating hypotension and potential borderline shock.
Metoprolol is a beta-blocker that will further lower blood pressure and heart rate, so it must be withheld to prevent hemodynamic collapse.
3
Review the IV push bumetanide order.
Administering IV push medications requires RN-level assessment and intervention.
This task is outside the legal scope of practice for a PN, requiring immediate escalation to the RN.
4
Assess the remaining scenarios for safety.
A potassium level of 4.2 mEq/L is normal. Mild arm soreness is an expected vaccine reaction. Using a wristband and barcode for an aphasic client is a standard safe identification method.
These three scenarios represent safe, expected clinical situations where the PN should proceed with medication administration independently.

Key Concept

Pharmacological safety and PN scope of practice require recognizing critical laboratory values, identifying borderline vital signs indicating potential shock, and escalating tasks requiring RN-level intervention (such as IV push administration).
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Topics

Pharmacological Therapies

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