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Difficulty: HardReduction of Risk Potential

A licensed practical nurse (LPN) is providing care for a 52-year-old client admitted with an acute upper gastrointestinal hemorrhage. The client is receiving continuous intravenous (IV) fluids and is on bed rest. Which of the following actions by the LPN are essential to minimize the client's risk of further complications? Select all that apply.

  1. Notify the registered nurse promptly if the client's resting heart rate steadily increases from 82 to 110 beats per minute.Answer
  2. B
    Administer a prescribed intravenous push (IVP) dose of a proton pump inhibitor to rapidly manage the condition.
  3. Verify the client's identity using two distinct identifiers prior to administering any prescribed oral medications.Answer
  4. D
    Withhold verbal escalation of a critical serum hemoglobin result of 6.9 g/dL (69 g/L) since the value is available in the electronic health record.
  5. E
    Document a blood pressure decrease from 128/80 mm Hg to 104/68 mm Hg as a benign finding requiring no further escalation.
  6. Assist the client into a side-lying position immediately if they begin to experience active hematemesis.Answer

Answer

The essential actions are to notify the registered nurse of the increasing heart rate, verify the client's identity with two identifiers before medication administration, and place the client in a side-lying position during active hematemesis.
In a client with an acute gastrointestinal hemorrhage, the primary risks are hypovolemic shock and airway compromise. An increasing heart rate is an early compensatory sign of hypovolemia that must be escalated immediately. Verifying patient identity with two identifiers is a fundamental standard to prevent medication errors. Positioning a client in a side-lying position during active vomiting (hematemesis) uses gravity to drain emesis and prevents aspiration, thus protecting the airway.

Step-by-Step Solution

1
Analyze the clinical scenario to identify the primary physiological risks for a client with an acute gastrointestinal hemorrhage.
The client is at high risk for hypovolemic shock due to blood loss and at risk for aspiration due to potential hematemesis.
Identifying the core physiological risks directs the prioritization of care and necessary risk reduction strategies.
2
Evaluate the assessment findings (heart rate and blood pressure) for early signs of hypovolemic shock.
An increasing heart rate (82 to 110 bpm) and a decreasing blood pressure (128/80 to 104/68 mm Hg) are compensatory mechanisms for blood loss and indicate impending shock.
Early recognition of subtle vital sign changes allows for prompt escalation and intervention before the client severely decompensates.
3
Assess the procedural and scope-of-practice actions for safety and legal compliance.
Verifying identity with two identifiers is a mandatory safety step. Administering IV push medications is outside the LPN scope of practice. Critical labs (hemoglobin 6.9 g/dL) require direct verbal reporting.
Adhering strictly to safety standards and the LPN scope of practice reduces the risk of iatrogenic injury and ensures appropriate care delivery.
4
Determine the correct physical positioning for a client experiencing active hematemesis.
The side-lying position is selected to allow emesis to drain from the mouth.
This position uses gravity to protect the airway and prevent aspiration of blood into the lungs.

Key Concept

Reduction of Risk Potential: Early Shock Recognition and Scope of Practice
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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