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Difficulty: MediumReduction of Risk Potential

The practical nurse (PN) is providing care for a group of clients on a medical-surgical unit. Which of the following actions by the PN demonstrate appropriate risk reduction and safe clinical practice? Select all that apply.

  1. Notifying the registered nurse (RN) immediately regarding a client receiving a loop diuretic whose morning serum potassium level is 2.8 mEq/L (2.8 mmol/L).Answer
  2. B
    Administering a prescribed intravenous push (IVP) analgesic to a client experiencing acute postoperative pain.
  3. C
    Documenting a new-onset resting heart rate of 114 bpm and a blood pressure of 88/56 mm Hg as expected findings for an older adult.
  4. Verifying the client's name and date of birth using the identification band prior to providing scheduled oral medications.Answer
  5. E
    Identifying a client for a procedure by relying on visual recognition because the client has been on the unit for several weeks.
  6. Placing a client with right-sided weakness on a scheduled toileting protocol to prevent unassisted ambulation attempts.Answer

Answer

The correct actions are notifying the RN of the critically low potassium level, verifying two client identifiers before medication administration, and implementing a scheduled toileting protocol for a client with weakness.
The correct choices reflect safe clinical practice strictly within the practical nurse scope. Escalating a critically low hypokalemia value, adhering to mandatory two-identifier verification, and implementing proactive fall prevention strategies all directly reduce the risk of harm to vulnerable clients.

Step-by-Step Solution

1
Analyze the PN scope of practice regarding medication administration and delegation constraints.
Intravenous push (IVP) medications require RN-level assessment and are outside the standard PN scope.
Accepting tasks beyond legal scope increases the risk of client harm and violates professional licensure standards.
2
Evaluate vital signs and laboratory data to differentiate between expected variations and critical abnormalities.
A potassium level of 2.8 mEq/L and vital signs showing tachycardia with hypotension are critical findings.
These findings indicate severe physiological compromise (hypokalemia and potential shock) requiring immediate medical or RN intervention.
3
Review standard safety protocols for client identification and fall prevention.
Checking two distinct identifiers and implementing scheduled toileting are mandated safety practices.
Visual recognition bypasses safety checks, leading to medication errors, while unassisted ambulation in weak clients leads to falls. Proper protocols reduce these risks.

Key Concept

Scope of Practice and Clinical Prioritization in Risk Reduction
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Topics

Reduction of Risk Potential

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