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Difficulty: HardReduction of Risk Potential

A practical nurse (PN) is providing care for an older adult client admitted with severe community-acquired pneumonia. During the morning assessment, the client appears increasingly lethargic. The PN obtains the following vital signs: Temperature 100.4°F (38.0°C), Heart rate 116 bpm, Respiratory rate 24 breaths/min, and Blood pressure 86/54 mmHg. The morning laboratory results reveal a white blood cell (WBC) count of 18,000/mm318,000/\text{mm}^3 (18×109/L18 \times 10^9/\text{L}) and a serum lactate level of 4.2 mmol/L4.2\text{ mmol/L} (normal: 0.50.5 to 1.0 mmol/L1.0\text{ mmol/L}). Which of the following actions should the PN take? Select all that apply.

  1. Immediately report the client's vital signs and lethargy to the supervising registered nurse.Answer
  2. B
    Document the vital signs and reassess in 2 hours, as mild hypotension is expected during sleep.
  3. C
    Note the elevated serum lactate level in the chart without verbal escalation, assuming it is a known consequence of the pneumonia.
  4. Gather equipment to assist the registered nurse with drawing blood cultures and administering prescribed intravenous fluids.Answer
  5. E
    Independently increase the rate of the client's continuous intravenous normal saline infusion to treat the low blood pressure.
  6. Verify the client's identity using two unique identifiers prior to the administration of newly prescribed intravenous antibiotics.Answer

Answer

The correct actions are to immediately report the vital signs and lethargy to the supervising registered nurse, gather equipment to assist with blood cultures and fluid administration, and verify the client's identity using two identifiers before administering antibiotics.
The client is demonstrating classic signs of sepsis progressing to septic shock, indicated by tachycardia, hypotension, lethargy, leukocytosis, and a critically elevated serum lactate level. In this scenario, reducing risk potential requires immediate escalation to the registered nurse for urgent medical intervention. Assisting the registered nurse by gathering necessary equipment for fluid resuscitation and blood cultures facilitates timely, life-saving treatment. Additionally, adhering to strict safety protocols, such as using two unique identifiers before administering medications, is a fundamental risk reduction strategy within the practical nursing scope of practice.

Step-by-Step Solution

1
Analyze the clinical presentation and diagnostic data.
The client is exhibiting tachycardia, hypotension, tachypnea, fever, lethargy, leukocytosis, and a critically high lactate level.
Recognizing the constellation of symptoms associated with systemic infection progressing to septic shock is crucial for reducing the risk of severe morbidity or mortality.
2
Determine appropriate practical nursing actions within the scope of practice.
The PN must escalate the critical findings immediately to the RN, assist with urgent interventions (gathering supplies), and maintain strict safety standards (two identifiers for medications).
PNs play a critical role in data collection, early complication recognition, and safe care delivery under RN supervision.
3
Identify incorrect or out-of-scope actions to avoid.
Delaying notification, assuming abnormal critical labs do not require verbal reporting, and independently changing IV infusion rates are incorrect.
These actions violate the PN scope of practice, misinterpret the severity of the data, and fail to address the life-threatening nature of the client's condition.

Key Concept

Early recognition of shock indicators and immediate escalation within the PN scope of practice.
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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