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Difficulty: EasyReduction of Risk Potential

A practical nurse (PN) is evaluating a client on the first postoperative day following an exploratory laparotomy. Which actions or clinical decisions by the PN are appropriate to reduce the risk of postoperative complications? Select all that apply.

  1. Verifying the client's identity using two distinct identifiers before administering prescribed oral analgesics.Answer
  2. B
    Filing a laboratory report showing a hemoglobin level of 7.4 g/dL (74 g/L) without immediately notifying the registered nurse.
  3. Assisting the client to perform turning, coughing, and deep breathing exercises every 2 hours.Answer
  4. D
    Attributing a new heart rate of 115 beats/minute and a blood pressure of 92/58 mm Hg solely to expected surgical pain.
  5. Applying prescribed sequential compression devices (SCDs) to the client's lower extremities while resting in bed.Answer
  6. F
    Accepting a task from the registered nurse to administer an intravenous (IV) push dose of an opioid analgesic.

Answer

The correct actions to reduce risk are verifying the client's identity with two identifiers, assisting with turning and deep breathing, and applying sequential compression devices.
Verifying identity with two identifiers prevents medication errors. Turning, coughing, and deep breathing prevent respiratory complications like atelectasis. Applying sequential compression devices prevents venous thromboembolism. All three are essential interventions to reduce the risk of complications in a postoperative client.

Step-by-Step Solution

1
Evaluate the interventions aimed at preventing postoperative complications.
Turning, deep breathing, and applying sequential compression devices are recognized strategies to prevent pneumonia and deep vein thrombosis.
Postoperative clients are at high risk for respiratory and circulatory complications due to anesthesia and immobility.
2
Identify safe medication administration practices.
Checking two distinct identifiers is required before administering any medication to prevent errors.
Strict adherence to the rights of medication administration reduces the risk of adverse pharmacological events.
3
Assess the remaining options for unsafe practices or errors in clinical judgment.
Ignoring critical lab values (hemoglobin 7.4 g/dL), dismissing borderline shock signs (tachycardia and hypotension), and accepting IV push delegations are unsafe.
These actions fail to mitigate risks, violate the practical nurse's scope of practice, and could lead to severe client harm.

Key Concept

The practical nurse reduces risk potential by implementing preventative care measures, adhering to safe medication administration protocols, and promptly escalating abnormal clinical findings.
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Reduction of Risk Potential

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