Examkin

Question

Difficulty: MediumReduction of Risk Potential

A licensed practical nurse (LPN) is providing care for a client admitted with bilateral pneumonia who is receiving intravenous antibiotics. Which of the following actions by the LPN demonstrate appropriate risk reduction principles and safe practice? Select all that apply.

  1. Verifying the client's identity using their full name and date of birth before administering a scheduled oral antipyretic.Answer
  2. B
    Waiting until the end of the shift to communicate a morning serum potassium level of 2.82.8 mEq/L (2.82.8 mmol/L) to the registered nurse.
  3. C
    Accepting a delegated task from the charge nurse to perform an initial comprehensive admission assessment on a newly arrived client.
  4. Elevating the head of the client's bed to a semi-Fowler's position to promote optimal lung expansion and airway clearance.Answer
  5. E
    Attributing a new resting heart rate of 114114 bpm and a blood pressure of 96/5496/54 mm Hg to anxiety without further escalation.
  6. Promptly notifying the registered nurse that the client's oxygen saturation has declined from 96%96\% to 89%89\% on room air.Answer

Answer

The correct actions are verifying the client's identity using two identifiers, elevating the head of the bed, and promptly notifying the registered nurse about the decreased oxygen saturation.
Verifying identity using two distinct identifiers ensures correct medication administration and prevents errors. Elevating the head of the bed is an independent nursing intervention that facilitates optimal respiratory function for a client with pneumonia. Finally, promptly reporting an oxygen saturation drop from 96% to 89% allows for timely assessment and potential adjustment of respiratory support to prevent further hypoxia.

Step-by-Step Solution

1
Evaluate each action for adherence to the LPN scope of practice and risk reduction principles.
Identify actions that promote client safety and correctly escalate abnormal findings.
The LPN is responsible for identifying potential complications, safely administering care, and communicating changes in client status to the RN.
2
Analyze the laboratory and vital sign data provided in the options.
Determine that a potassium level of 2.8 mEq/L and an oxygen saturation of 89% are critical abnormalities requiring immediate escalation.
Hypokalemia and hypoxia pose immediate risks to the client's physiological stability.
3
Review the nursing actions for scope of practice and medication safety.
Determine that initial comprehensive assessments are outside the LPN scope, and utilizing two identifiers is required for medication administration.
LPNs perform focused, not initial comprehensive, assessments. Two distinct client identifiers are required for safe medication administration.

Key Concept

The practical nurse plays a critical role in reducing risk potential by recognizing and escalating abnormal clinical findings, adhering strictly to medication administration rights, and working within their defined scope of practice.
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic