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Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is monitoring a client admitted with acute pancreatitis who is receiving continuous intravenous (IV) fluids. Which of the following findings or situations require the PN to immediately escalate care to the registered nurse (RN)? Select all that apply.

  1. A blood pressure of 86/54 mm Hg and a heart rate of 118 beats/minuteAnswer
  2. A positive Chvostek sign with a serum calcium level of 7.2 mg/dL (1.8 mmol/L)Answer
  3. A new prescription for intravenous push (IVP) morphine for severe abdominal painAnswer
  4. D
    A serum amylase level of 520 U/L
  5. E
    A temperature of 99.8°F (37.7°C) and a respiratory rate of 18 breaths/minute
  6. F
    A client request to leave a scheduled oral medication at the bedside

Answer

The situations requiring immediate RN escalation are the hypotensive and tachycardic vital signs, the positive Chvostek sign with hypocalcemia, and the prescription for intravenous push (IVP) morphine.
The correct selections represent clinical emergencies and scope of practice limitations. Hypotension with tachycardia suggests hypovolemic shock, a major risk in pancreatitis due to third-spacing of fluids. A low serum calcium level (normal 9.0-10.5 mg/dL) with a positive Chvostek sign indicates impending tetany, requiring urgent RN intervention. Finally, the administration of intravenous push (IVP) medications falls outside the standard practical nurse scope of practice, requiring the RN to assume this task.

Step-by-Step Solution

1
Analyze the client's vital signs for indications of systemic complications.
A blood pressure of 86/54 mm Hg with a heart rate of 118 beats/minute indicates potential hypovolemic shock (third-spacing).
Hypovolemic shock is a severe complication of acute pancreatitis requiring immediate RN and provider intervention.
2
Evaluate the laboratory results and physical assessment findings.
A calcium level of 7.2 mg/dL is critically low, and a positive Chvostek sign confirms symptomatic hypocalcemia.
Symptomatic hypocalcemia can lead to tetany and requires immediate RN escalation for IV calcium administration.
3
Review the medication orders against the practical nurse (PN) scope of practice.
The prescription includes intravenous push (IVP) morphine.
IVP medications are outside the standard PN scope of practice; therefore, the RN must be notified to administer the medication.
4
Differentiate between expected disease findings and true emergencies.
An elevated serum amylase, a mild temperature elevation, and a request to leave medications at the bedside do not require RN escalation.
The PN can independently monitor expected diagnostic findings (amylase), benign vitals, and enforce standard medication safety rights.

Key Concept

Reduction of risk potential requires the practical nurse to recognize life-threatening complications (e.g., hypovolemic shock, symptomatic hypocalcemia) and identify tasks outside their scope of practice (e.g., IVP medications) to promptly escalate care to the registered nurse.
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Reduction of Risk Potential

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