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Difficulty: MediumReduction of Risk Potential

During a shift on an acute care medical-surgical unit, a practical nurse (PN) is tasked with managing care for several clients. Which of the following nursing actions demonstrate appropriate risk reduction and adherence to safe practice guidelines? (Select all that apply.)

  1. Implementing daily weights and strict intake and output monitoring for a client admitted with an acute exacerbation of heart failure.Answer
  2. Verifying the client's ability to swallow effectively before providing oral fluids following an acute ischemic stroke.Answer
  3. C
    Accepting an assignment to independently manage a client who requires continuous titration of an intravenous (IV) antiarrhythmic medication.
  4. D
    Administering scheduled medications by relying solely on the client's verbal confirmation of their name when the unit's barcode scanner is broken.
  5. E
    Placing a laboratory report indicating a serum sodium level of 118 mEq/L in the chart for the provider to review during routine afternoon rounds.
  6. F
    Attributing a postoperative client's steadily increasing heart rate and borderline hypotension strictly to surgical pain without further escalation.

Answer

The correct actions are implementing daily weights and strict intake/output monitoring for the client with heart failure, and verifying the swallowing ability of the client who experienced a stroke.
Safe risk reduction involves implementing evidence-based basic care (such as daily weights for heart failure to monitor fluid status) and preventing complications (such as assessing swallowing after a stroke to prevent aspiration). Both actions fall safely within the practical nurse's scope of practice and directly protect the client from harm.

Step-by-Step Solution

1
Evaluate the heart failure intervention.
Daily weights and intake/output monitoring are identified as appropriate.
These are standard, evidence-based practices to reduce the risk of fluid volume overload complications.
2
Evaluate the stroke intervention.
Verifying swallowing ability is identified as appropriate.
This is a necessary risk reduction measure to prevent aspiration before introducing oral intake.
3
Analyze the IV titration assignment.
Identified as an unsafe practice.
Managing continuous IV antiarrhythmic drips exceeds the practical nurse scope and requires RN-level monitoring.
4
Analyze the medication verification method.
Identified as a safety violation.
Using only one identifier (verbal name) breaches medication safety protocols; two distinct identifiers are always required.
5
Review the handling of the lab report.
Identified as a failure to escalate.
A sodium level of 118 mEq/L is critically low and requires immediate verbal notification, not passive charting.
6
Analyze the vital signs interpretation.
Identified as a missed clinical warning.
Tachycardia with borderline hypotension are early signs of shock and must be reported immediately, rather than assumed to be pain.

Key Concept

Identifying clinical risks and escalating care appropriately within the practical nurse scope of practice.
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Topics

Reduction of Risk Potential

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