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Difficulty: Very hardReduction of Risk Potential

A practical nurse (PN) is performing focused assessments on a group of assigned clients. Which of the following client situations are considered expected or stable, allowing the nurse to safely document the data and continue routine care WITHOUT immediately notifying the registered nurse (RN)? Select all that apply.

  1. A client with a new left forearm arteriovenous (AV) fistula who has a continuous palpable thrill and an audible bruit at the access site.Answer
  2. A client 12 hours post-laparoscopic cholecystectomy who reports mild right shoulder pain and has hypoactive bowel sounds.Answer
  3. C
    A client receiving an intravenous heparin infusion whose morning platelet count is 85,000/mm³ (85 × 10⁹/L).
  4. D
    A client 2 hours post-thoracentesis who exhibits new-onset mild restlessness and a respiratory rate of 26 breaths/minute.
  5. A client with an indwelling urinary catheter whose total urine output over the previous 4 hours is 160 mL.Answer
  6. F
    A client with a prescription to titrate an intravenous diltiazem infusion based on continuous telemetry parameters.

Answer

The correct selections are the client with the functioning AV fistula, the client with expected post-laparoscopic cholecystectomy findings, and the client with adequate urinary output.
The practical nurse must apply risk reduction principles by filtering benign, expected data from clinical emergencies. A palpable thrill and audible bruit prove that an AV fistula is patent and functioning properly. Right shoulder pain after a laparoscopic procedure is a common, non-emergent consequence of the carbon dioxide gas used to inflate the abdomen, and bowel sounds naturally remain sluggish after anesthesia. A urine output averaging 40 mL/hour comfortably exceeds the minimum safety threshold of 30 mL/hour. All of these situations reflect stable clients progressing as expected, allowing the PN to document the findings and proceed with routine care.

Step-by-Step Solution

1
Evaluate the assessment data for the client with the AV fistula.
A thrill and bruit are identified at the site.
These findings confirm normal, healthy blood flow through a newly created fistula and do not require escalation.
2
Analyze the post-operative findings for the client who underwent a laparoscopic cholecystectomy.
Right shoulder pain and hypoactive bowel sounds are present 12 hours post-surgery.
Both findings are expected physiological responses to abdominal insufflation and general anesthesia, respectively.
3
Calculate the hourly urine output for the client with the catheter.
160 mL divided by 4 hours equals 40 mL/hour.
This is above the critical minimum threshold of 30 mL/hour, demonstrating adequate organ perfusion and stability.
4
Identify the complications and scope-of-practice issues in the remaining scenarios.
The platelet count is critically low, the thoracentesis client is showing early shock/hypoxia signs, and the diltiazem titration is beyond PN scope.
These three situations carry high risk potential and mandate immediate notification of the RN to ensure client safety.

Key Concept

Distinguishing between expected clinical progression and subtle indicators of complications to determine when RN escalation is required.
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Topics

Reduction of Risk Potential

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