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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is providing care for several clients on a medical-surgical unit. Which of the following nursing actions best demonstrate appropriate reduction of risk potential and adherence to safe clinical practice? Select all that apply.

  1. Verifying two distinct client identifiers, such as name and date of birth, prior to drawing a blood sample for a type and crossmatch.Answer
  2. Elevating the head of the bed and notifying the registered nurse (RN) immediately when a client receiving continuous enteral feedings develops new-onset coarse crackles.Answer
  3. C
    Filing a morning laboratory report with a serum potassium level of 2.8 mEq/L (2.8 mmol/L) without alerting the RN because the client denies experiencing any symptoms.
  4. D
    Documenting a postoperative client's new resting heart rate of 114 beats per minute and blood pressure of 92/58 mm Hg without further escalation because the client is resting quietly.
  5. E
    Administering a prescribed dose of intravenous (IV) push furosemide to rapidly diurese a client experiencing acute pulmonary edema.
  6. F
    Bypassing the scanning of a client's identification wristband before administering an oral medication because the bedside barcode scanner is temporarily malfunctioning.

Answer

The correct actions include verifying two distinct client identifiers before drawing blood for a crossmatch and elevating the head of the bed while notifying the RN for a client with enteral feedings who develops coarse crackles.
The correct nursing actions actively protect the client from harm. Consistently verifying two distinct identifiers prevents wrong-client errors during high-risk procedures like blood typing. Additionally, recognizing new-onset crackles during enteral feeding as a sign of potential aspiration and intervening by raising the head of the bed and notifying the RN demonstrates competent risk mitigation.

Step-by-Step Solution

1
Analyze each option to determine if the nursing action is safe, within the PN scope of practice, and effectively reduces client risk.
Identify actions that proactively prevent complications (e.g., rigorously verifying identifiers, escalating acute respiratory distress).
Risk reduction requires the PN to anticipate potential harm and take preventative or rapid corrective measures.
2
Evaluate the clinical data provided in the incorrect options against normal physiological parameters and the legal scope of practice.
Recognize that a potassium of 2.8 mEq/L is a critical lab value, IV push medications are out of scope, borderline hypotensive vitals indicate potential shock, and skipping safety checks violates medication administration rights.
Identifying what the PN should NOT do is just as important as knowing correct interventions in order to maintain a strictly safe care environment.

Key Concept

The practical nurse effectively reduces risk potential by closely monitoring for early signs of complications, strictly adhering to safety protocols, recognizing critical clinical data, and maintaining boundaries within their legal scope of practice.
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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