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Difficulty: MediumPharmacological Therapies

A 68-year-old client is recovering from abdominal surgery. The practical nurse (PN) is reviewing the medication administration record and current client data. The client's vital signs are: blood pressure 88/54 mm Hg, heart rate 118 beats/min, and respiratory rate 20 breaths/min. The provider has prescribed oral lisinopril, subcutaneous enoxaparin, and a continuous intravenous (IV) analgesic infusion. Which of the following actions by the PN are correct? Select all that apply.

  1. Withholding the scheduled oral lisinopril and notifying the registered nurse (RN) of the current vital signs.Answer
  2. Reinforcing education with the client regarding bleeding precautions prior to the enoxaparin injection.Answer
  3. Administering the subcutaneous enoxaparin injection into the anterolateral abdominal wall.Answer
  4. D
    Titrating the continuous intravenous (IV) analgesic infusion based on the client's self-reported pain score.
  5. E
    Bypassing the two-identifier verification check before medication administration because the client is well known to the nurse.
  6. F
    Interpreting the client's tachycardia and hypotension as normal postoperative findings and continuing with scheduled care.

Answer

The correct actions are withholding the lisinopril and notifying the RN, reinforcing bleeding precautions, and administering the enoxaparin into the anterolateral abdominal wall.
The practical nurse demonstrates safe care by withholding the antihypertensive medication in the presence of significant hypotension and escalating the abnormal vital signs to the RN. Furthermore, reinforcing previously taught information about bleeding risks associated with anticoagulants and utilizing the correct anatomical site (abdomen) for subcutaneous enoxaparin are safe, standard practices within the practical nursing scope.

Step-by-Step Solution

1
Analyze the client's vital signs in relation to the prescribed medications.
The client is hypotensive (88/54 mm Hg) and tachycardic (118 beats/min). Lisinopril is contraindicated at this time.
Administering an antihypertensive to a hypotensive client compromises safety and perfusion.
2
Evaluate the remaining tasks against the PN scope of practice.
Reinforcing teaching and administering subcutaneous injections are within the PN scope. Titrating IV infusions is out of scope.
The PN must only perform tasks that are legally and clinically within their designated role.
3
Review standard medication administration procedures.
Two client identifiers must always be checked, and abnormal vital signs must be reported, not ignored.
Adhering to National Patient Safety Goals prevents medication errors and recognizes early signs of clinical deterioration.

Key Concept

Safe Pharmacological Administration and Scope of Practice
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Topics

Pharmacological Therapies

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