A practical nurse is providing care for a client who is day post-operative following an open abdominal surgery. Which of the following actions by the practical nurse demonstrate appropriate risk reduction and safe clinical practice? Select all that apply.
- Verifying two distinct client identifiers by checking the identification band prior to administering a prescribed oral analgesic.Answer
- Notifying the registered nurse (RN) immediately regarding a morning serum potassium result of ().Answer
- Escalating care to the RN when the client's resting heart rate increases to with a blood pressure of .Answer
- DPlacing a firm pillow directly under the client's knees to help relieve tension on the abdominal incision.
- EAdministering a prescribed intravenous (IV) push antiemetic medication to treat the client's sudden onset of nausea.
- FDelaying the report of an oxygen saturation of on room air because the client is currently sleeping comfortably.
Answer
The correct actions include verifying two client identifiers before medication administration, immediately notifying the RN of a critical potassium level, and escalating care for borderline vital signs indicating potential shock.
Safe practical nursing care requires strict adherence to risk reduction principles. This includes mandatory safety checks like verifying two distinct client identifiers. Furthermore, the practical nurse plays a critical role in early complication detection by identifying and immediately escalating critical laboratory values (such as a severely low potassium level of , which risks cardiac dysrhythmias) and subtle signs of impending complications (such as unexpected tachycardia and hypotension, which are early indicators of hypovolemic shock or hemorrhage).
Step-by-Step Solution
Key Concept
Reduction of Risk Potential: Recognizing Complications and Scope of Practice