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Difficulty: MediumReduction of Risk Potential

A charge nurse in an acute care facility is observing a newly licensed practical nurse (PN) provide care to a group of assigned clients. Which of the following actions by the PN require immediate intervention by the charge nurse? Select all that apply.

  1. Filing a laboratory report showing a serum potassium level of 2.8 mEq/L without verbally notifying the registered nurse (RN)Answer
  2. Documenting a postoperative client's heart rate of 118 beats/min and blood pressure of 88/54 mm Hg and proceeding to evaluate the next clientAnswer
  3. Administering a scheduled oral antibiotic after verifying the client's identity using only the room number on the doorAnswer
  4. D
    Reinforcing the RN's initial discharge education regarding signs and symptoms of a surgical site infection
  5. E
    Withholding a scheduled dose of oral digoxin when the client's apical pulse is 52 beats/min and notifying the RN
  6. F
    Collecting a sterile urine specimen from a closed indwelling urinary catheter system for laboratory analysis

Answer

The actions requiring intervention are filing a critically low potassium level without verbal notification, ignoring borderline vital signs indicative of postoperative shock, and verifying a client's identity using only a room number.
The correct selections represent dangerous practice errors that compromise client safety. Failing to verbally escalate a critically low potassium level, ignoring early vital sign trends indicative of postoperative shock, and bypassing proper two-identifier medication verification are all serious violations of risk reduction protocols that require immediate correction by the charge nurse.

Step-by-Step Solution

1
Analyze the role and scope of practice of the practical nurse (PN) in an acute care setting.
The PN is responsible for collecting data, recognizing abnormal findings, escalating critical changes to the RN, and adhering to strict safety protocols.
Understanding the boundaries of the PN scope is necessary to identify when an action is unsafe.
2
Evaluate each action to determine if it violates safety standards or represents a failure to reduce client risk.
Failing to report a potassium of 2.8 mEq/L, ignoring early shock vitals, and using a room number for medication administration are all critical safety violations.
These specific actions place the clients at immediate risk for fatal arrhythmias, unmanaged hemorrhage, and medication errors.
3
Differentiate the unsafe actions from those that are appropriate within the PN scope.
Reinforcing teaching, properly withholding digoxin for bradycardia, and collecting a sterile catheter specimen are all safe, standard PN responsibilities that do not require intervention.
This confirms which specific actions the charge nurse needs to correct immediately.

Key Concept

Risk Reduction and Practical Nurse Scope of Practice
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Topics

Reduction of Risk Potential

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