An older adult client is receiving care on a medical unit for a suspected upper gastrointe… — NCLEX-PN

An older adult client is receiving care on a medical unit for a suspected upper gastrointestinal bleed. The morning laboratory report indicates a hemoglobin level of $6.9 \text{ g/dL}$ and a serum potassium of $2.8 \text{ mEq/L}$ . The client's current vital signs are: blood pressure $96/60 \text{ mm Hg}$ , apical pulse $116 \text{ beats/minute}$ , and respirations $22 \text{/minute}$ . A registered nurse (RN) prepares a prescribed intravenous (IV) piggyback of potassium chloride, hands the bag to the practical nurse (PN), and delegates the medication administration and subsequent monitoring of this client. Which action is most appropriate for the PN to take?

Decline the delegation, as caring for a hemodynamically unstable client with critical laboratory abnormalities requires continuous registered nurse (RN) assessment.Answer
B
Accept the assignment but initiate vital sign checks every 15 minutes, attributing the client's tachycardia and mild hypotension to the expected effects of dehydration.
C
Administer the IV potassium chloride to resolve the hypokalemia, and document the low hemoglobin in the electronic health record for the provider to review during afternoon rounds.
D
Proceed with hanging the IV medication at the prescribed rate, relying on the RN's verbal confirmation of the correct medication and client identity to save time.

Answer

The practical nurse must decline the delegation because the client is exhibiting signs of hemodynamic instability and hypovolemic shock, which requires the advanced assessment skills of a registered nurse.

The client is demonstrating clear signs of active bleeding and hypovolemic shock (hemoglobin

6.9 \text{ g/dL}

, hypotension, tachycardia) alongside severe hypokalemia. Caring for a hemodynamically unstable client requires advanced physiological assessment, clinical judgment, and immediate intervention that falls exclusively within the scope of practice of a registered nurse (RN). The practical nurse (PN) must advocate for client safety by declining this inappropriate delegation.

Step-by-Step Solution

Analyze the laboratory data provided in the scenario.

The client has a hemoglobin of

6.9 \text{ g/dL}

(critically low, indicating severe blood loss) and a potassium of

2.8 \text{ mEq/L}

(critically low, risking cardiac dysrhythmias).

Identifying abnormal laboratory values is essential for recognizing physiological risk.

Analyze the vital signs in the context of the client's diagnosis.

A blood pressure of

96/60 \text{ mm Hg}

and a heart rate of

116 \text{ beats/minute}

in a client with a suspected gastrointestinal bleed indicate compensatory tachycardia and hypotension.

These are classic early signs of hypovolemic shock, meaning the client's condition is actively deteriorating.

Evaluate the appropriateness of the RN's delegation.

The RN is delegating the care, medication administration, and monitoring of a highly unstable client to the PN.

The PN scope of practice involves caring for clients with predictable outcomes. Unstable clients require advanced assessment and clinical judgment.

Determine the correct nursing action based on scope of practice.

The PN must decline the unsafe assignment to protect the client and practice safely within legal boundaries.

Accepting an unstable client assignment violates the PN scope of practice and places the client at severe risk for adverse outcomes.

Key Concept

Reduction of Risk Potential through appropriate delegation and recognition of hemodynamic instability.

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