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Difficulty: EasyReduction of Risk Potential

A practical nurse (PN) is providing care for several clients on a medical-surgical unit. Which actions by the PN demonstrate appropriate risk reduction strategies? (Select all that apply)

  1. Verifying the client's name and date of birth before administering a scheduled dose of oral medication.Answer
  2. Immediately notifying the registered nurse (RN) when a client's morning fasting blood glucose is 42 mg/dL.Answer
  3. Escalating to the charge nurse when a postoperative client's heart rate gradually increases to 115 beats per minute with decreasing blood pressure.Answer
  4. D
    Waiting to report a critical laboratory result of a hemoglobin level at 6.5 g/dL until the healthcare provider rounds later in the afternoon.
  5. E
    Assuming a blood pressure of 88/50 mm Hg is a normal, expected finding for an older adult client who just returned from surgery.
  6. F
    Accepting a delegated task from the RN to administer an initial dose of intravenous (IV) push morphine to a client in severe pain.

Answer

The correct actions include verifying two distinct client identifiers before administering medication, immediately escalating a critically low blood glucose level, and promptly reporting vital sign trends that suggest early shock.
Appropriate risk reduction requires the practical nurse to strictly follow established safety protocols (such as using two identifiers for medications) and to immediately recognize and escalate life-threatening clinical changes. A blood glucose of 42 mg/dL represents critical hypoglycemia requiring immediate treatment. A rising heart rate combined with a dropping blood pressure is a classic early indicator of hypovolemic shock or hemorrhage that must be reported to the RN immediately.

Step-by-Step Solution

1
Evaluate the medication safety and scope of practice actions.
Verifying two identifiers is correct. Accepting an IV push medication assignment is incorrect because it is outside the PN scope of practice.
Risk reduction requires strict adherence to medication safety protocols and legal practice boundaries.
2
Evaluate the laboratory value management actions.
Immediately reporting a blood glucose of 42 mg/dL is correct. Delaying the report of a 6.5 g/dL hemoglobin level is incorrect.
Both values are critical. Delaying notification of critical labs directly increases client risk.
3
Evaluate the vital sign assessment actions.
Reporting tachycardia with hypotension is correct. Dismissing a blood pressure of 88/50 mm Hg as normal is incorrect.
Changes in vital signs postoperatively are early indicators of hemorrhage or shock and must be escalated, never ignored.

Key Concept

Reduction of Risk Potential: Safety Protocols and Escalation
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Topics

Reduction of Risk Potential

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