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Difficulty: HardClient Care Assignments and Collaboration

During a routine compliance audit at a healthcare facility, an evaluator observes various interprofessional team interactions. Which action, performed independently by a practical nurse (PN), represents a violation of delegation standards and necessitates immediate correction?

  1. Adjusting the rate of a continuous intravenous (IV) heparin infusion in response to a client's recent activated partial thromboplastin time (aPTT).Answer
  2. B
    Co-signing an informed consent document strictly as a witness to the client's signature following the physician's detailed explanation.
  3. C
    Refusing to verify a client's admission status to a community visitor who lacks the designated family security passcode.
  4. D
    Auscultating lung sounds and measuring oxygen saturation to gather post-treatment data for the supervising registered nurse (RN).

Answer

Adjusting the rate of a continuous intravenous (IV) heparin infusion in response to a client's recent activated partial thromboplastin time (aPTT).
Titrating continuous intravenous infusions of high-alert medications, such as heparin, requires comprehensive clinical judgment, interpretation of dynamic laboratory values, and advanced assessment skills. These responsibilities fall strictly under the registered nurse (RN) scope of practice. A practical nurse (PN) performing this task is acting outside their legal scope, representing a severe safety violation.

Step-by-Step Solution

1
Analyze the prompt's requirement.
The question asks to identify an action that violates the practical nurse (PN) scope of practice or safety standards.
Understanding whether you are looking for a correct action or a violation is critical for priority questions.
2
Evaluate the scope regarding medication administration and IV therapy.
Titrating high-alert continuous IV infusions, such as heparin, requires clinical judgment and comprehensive assessment, which are strictly reserved for the registered nurse (RN).
The PN scope does not permit independent adjustment of critical drips based on laboratory values.
3
Evaluate the remaining clinical actions.
Witnessing consent, withholding protected health information from unauthorized visitors, and performing focused data collection (like lung sounds) are all standard and safe actions within the PN scope.
Differentiating between RN comprehensive assessment and PN data collection is essential for safe delegation.

Key Concept

Scope of Practice and Safe Delegation for the Practical Nurse
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Topics

Client Care Assignments and Collaboration

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