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Difficulty: MediumReduction of Risk Potential

A clinical team is managing a client who was admitted with a suspected upper gastrointestinal hemorrhage. A practical nurse (PN) is providing care during the day shift. Which of the following actions by the PN demonstrate appropriate risk reduction and safe clinical practice? (Select all that apply.)

  1. Alerting the charge nurse that the client's resting heart rate has trended upward from 84 to 110 beats per minute over two hours.Answer
  2. Communicating a morning hemoglobin result of 6.8 g/dL (68 g/L) directly to the supervising registered nurse without delay.Answer
  3. Scanning the client's identification band and verbally verifying their date of birth before providing an oral antacid.Answer
  4. D
    Independently adjusting the flow rate of the continuous intravenous (IV) normal saline based on the client's hourly urine output.
  5. E
    Waiting until the afternoon handoff to report a borderline blood pressure of 94/56 mm Hg because the client is resting quietly in bed.
  6. F
    Bypassing the barcode scanning system to administer an oral antiemetic quickly because the client is actively vomiting.

Answer

The correct actions include alerting the charge nurse of the upward trending heart rate, communicating the critically low hemoglobin result without delay, and scanning the identification band while verbally verifying the date of birth before administering medication.
These actions correctly identify and escalate subtle signs of shock and critical laboratory values while strictly adhering to safety protocols for medication administration. Prompt escalation allows the registered nurse and healthcare provider to intervene early in the event of an active hemorrhage.

Step-by-Step Solution

1
Analyze the clinical scenario
The client has a suspected gastrointestinal hemorrhage, placing them at high risk for hypovolemic shock, severe anemia, and sudden clinical deterioration.
Understanding the underlying pathology helps prioritize assessment findings and identify which data require immediate escalation.
2
Evaluate the assessment findings and laboratory data for critical thresholds
A heart rate increasing from 84 to 110 bpm and a hemoglobin of 6.8 g/dL both indicate worsening hemorrhage and require immediate escalation.
Early recognition of shock (tachycardia) and critical labs (severe anemia) reduces the risk of cardiovascular collapse.
3
Differentiate between actions within the PN scope of practice and those that exceed it
Reporting findings and utilizing medication safety systems are within the PN scope, whereas independently titrating IV fluids is outside the PN scope.
Maintaining client safety requires the practical nurse to act strictly within legal and professional boundaries.

Key Concept

Risk reduction for a client with a suspected hemorrhage involves early recognition of subtle shock signs, immediate escalation of critical laboratory values, strict adherence to medication safety protocols, and acting within the legal scope of practice.
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Reduction of Risk Potential

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