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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse is participating in the care of a client admitted with a suspected upper gastrointestinal bleed. Which action by the nurse demonstrates the appropriate application of risk reduction principles?

  1. Promptly notifying the registered nurse about a client blood pressure of 100/64 mm Hg and a heart rate of 108 beats/minAnswer
  2. B
    Noting a morning hemoglobin level of 6.5 g/dL (65 g/L) in the electronic health record to be reviewed during the provider's afternoon rounds
  3. C
    Verifying the client's identity by stating the client's name aloud and waiting for verbal confirmation before administering prescribed oral pantoprazole
  4. D
    Accepting a delegated task from the registered nurse to administer the first dose of intravenous push famotidine

Answer

Promptly notifying the registered nurse about a client blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min.
The client is at high risk for hypovolemic shock due to a gastrointestinal bleed. A slight drop in blood pressure paired with a rising heart rate (tachycardia) are early, subtle indicators that the body is attempting to compensate for blood loss. Prompt escalation to the registered nurse allows for early intervention, directly reducing the risk of severe cardiovascular collapse.

Step-by-Step Solution

1
Analyze the clinical scenario and the client's primary risk factor.
The client has a suspected upper gastrointestinal bleed, placing them at high risk for hypovolemia and hemorrhagic shock.
Understanding the client's diagnosis highlights the need to monitor for signs of active bleeding and impaired perfusion.
2
Evaluate each nursing action against safety guidelines and the practical nurse scope of practice.
Delaying critical lab reports, bypassing proper medication identifiers, and accepting IV push delegations are unsafe practices. Escalating borderline vital signs is a safe and required practice.
Risk reduction requires identifying early signs of deterioration and adhering strictly to safety protocols and scope of practice.
3
Select the action that best mitigates risk for the client.
Reporting the borderline low blood pressure and elevated heart rate directly addresses the immediate risk of shock.
Tachycardia and borderline hypotension are often the first physiological signs of significant blood loss.

Key Concept

Early recognition and escalation of subtle signs of shock (borderline vital signs) in clients with active bleeding risk.
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Topics

Reduction of Risk Potential

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