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Difficulty: MediumReduction of Risk Potential

A licensed practical nurse (LPN) is assisting with the care of a client who is 12 hours postoperative following an open cholecystectomy and has a nasogastric tube connected to low wall suction. Which of the following independent or collaborative actions by the LPN demonstrate appropriate risk reduction strategies? Select all that apply.

  1. Reporting a morning serum potassium level of 3.1 mEq/L (3.1 mmol/L) to the registered nurse immediately upon viewing the laboratory results.Answer
  2. B
    Attributing a new heart rate of 112 beats per minute and a blood pressure of 98/62 mm Hg to postoperative pain and administering prescribed oral analgesics without further escalation.
  3. C
    Silencing an intravenous infusion pump alarm and hanging a replacement bag of normal saline without rechecking the client's identification band, since the client was verified earlier in the shift.
  4. Verifying the placement of the nasogastric tube by assessing the pH of aspirated gastric contents prior to administering any prescribed enteral medications.Answer
  5. E
    Accepting a delegated task from the charge nurse to perform the initial admission assessment and develop the care plan for a new client transferred from the intensive care unit.
  6. Applying prescribed sequential compression devices (SCDs) to the client's lower extremities while the client is resting in bed.Answer

Answer

The correct risk reduction strategies are reporting the low potassium level, verifying nasogastric tube placement via pH aspirate, and applying sequential compression devices for venous thromboembolism prophylaxis.
Appropriate risk reduction requires the practical nurse to proactively identify and mitigate potential client harm. This includes recognizing abnormal laboratory values, such as a hypokalemic potassium level of 3.1 mEq/L caused by gastric suctioning, and immediately reporting them. Furthermore, implementing evidence-based practices like verifying nasogastric tube placement via aspirate pH and applying sequential compression devices directly prevents life-threatening complications such as pulmonary aspiration and deep vein thrombosis.

Step-by-Step Solution

1
Analyze the client's risk factors based on the clinical presentation.
The client is postoperative and undergoing continuous nasogastric suction, which introduces risks for hypovolemia, electrolyte imbalances (specifically hypokalemia), deep vein thrombosis, and aspiration.
Identifying specific risks based on the surgical procedure and active treatments guides the selection of appropriate preventative interventions.
2
Evaluate the laboratory finding and vital signs for necessary escalation.
The potassium level of 3.1 mEq/L is below the normal range (3.5-5.0 mEq/L) and must be reported. The vital signs (HR 112, BP 98/62) are borderline and suggest early shock, making it unsafe to attribute them solely to pain.
Risk reduction requires the timely recognition and communication of physiological deterioration.
3
Review the nursing actions for adherence to safety protocols and scope of practice.
Checking aspirate pH and applying SCDs are correct, safe practices. However, skipping patient identifiers for IV fluids and accepting an initial admission assessment violate core safety standards and the practical nursing scope of practice.
Bypassing established safety protocols or operating outside defined licensure limits directly increases the risk of client harm.

Key Concept

Reduction of Risk Potential requires the practical nurse to proactively identify early signs of complications (like abnormal labs or vital signs), verify the safe functioning of therapeutic devices, and adhere strictly to safety protocols and scope of practice boundaries.
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Reduction of Risk Potential

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