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Difficulty: HardClient Care Assignments and Collaboration

A client is two days post-operative following a right below-the-knee amputation. The client suddenly reports acute shortness of breath and right-sided chest pain. The practical nurse (PN) checks the client's vital signs and notes a heart rate of 124 beats/min, a respiratory rate of 28 breaths/min, and an oxygen saturation of 87% on room air. Which action demonstrates the most appropriate collaboration and safe scope of practice by the PN?

  1. A
    Administering a prescribed PRN intravenous (IV) push dose of morphine sulfate to alleviate the severe chest pain.
  2. Initiating standing orders for supplemental oxygen, performing a focused respiratory data collection, and immediately notifying the registered nurse (RN).Answer
  3. C
    Conducting a comprehensive cardiopulmonary assessment to determine the etiology of the symptoms and independently updating the primary care plan.
  4. D
    Explaining the potential complications of a suspected pulmonary embolism to the client and obtaining a signature for an emergency CT scan consent.

Answer

The most appropriate action is to initiate standing orders for supplemental oxygen, perform a focused respiratory data collection, and immediately notify the registered nurse (RN).
When a client experiences an acute, life-threatening change in condition, the client becomes 'unstable.' The PN must immediately initiate life-saving basic protocols (such as oxygen administration for hypoxia) and perform focused data collection, but they must promptly collaborate with the RN. The RN is legally required to assume care for the unstable client to perform a comprehensive assessment, synthesize the clinical findings, and execute advanced interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is experiencing sudden shortness of breath, chest pain, tachycardia, tachypnea, and hypoxia, indicating an acute and potentially life-threatening complication (likely a pulmonary embolism).
Recognizing a deteriorating, unstable client is the first step in determining the appropriate level of intervention and required collaboration.
2
Evaluate the legal boundaries of the PN scope of practice regarding acute client deterioration.
The PN cannot independently manage unstable clients, perform comprehensive initial assessments, formulate new care plans, or administer IV push medications.
Maintaining client safety requires strict adherence to licensure boundaries and state nurse practice acts.
3
Select the action that balances immediate safety needs with scope limitations.
Applying oxygen addresses the immediate hypoxia, gathering focused data provides necessary information for the medical team, and notifying the RN ensures the unstable client receives advanced assessment and care.
This sequence correctly applies the principles of prioritization (ABCs) and appropriate interprofessional collaboration.

Key Concept

The PN scope of practice involves focused data collection and implementation of basic care, while requiring immediate escalation to the RN when a client becomes hemodynamically unstable or requires comprehensive assessment.
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Topics

Client Care Assignments and Collaboration

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