Examkin

Soru

Zorluk: ZorReduction of Risk Potential

A client is receiving intravenous (IV) fluid therapy for severe dehydration caused by acute gastroenteritis. The practical nurse is collaborating with a registered nurse (RN) to manage the client's care. Which actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

  1. Alerting the RN that the client's heart rate has gradually increased from 84 to 110 beats per minute over the last two hours.Cevap
  2. Informing the healthcare provider that the practical nurse cannot administer a prescribed intravenous push (IVP) antiemetic medication.Cevap
  3. Stopping the IV fluid infusion and elevating the head of the bed when the client reports new-onset dyspnea and a tight chest.Cevap
  4. D
    Documenting a morning serum potassium level of 2.9 mEq/L and planning to assess for muscle weakness during the next scheduled rounds.
  5. E
    Bypassing the electronic barcode scanning process to administer a scheduled intravenous antibiotic while the scanner is temporarily offline.
  6. F
    Completing the comprehensive admission assessment and establishing the initial nursing care plan while the RN is occupied with an unstable client.

Cevap

The correct actions involve recognizing and escalating borderline vital signs (tachycardia), staying within the legal scope of practice by refusing to administer IV push medications, and intervening appropriately for early signs of fluid overload (dyspnea).
Risk reduction requires the practical nurse to identify early signs of complications (such as tachycardia indicating hypovolemia or dyspnea indicating fluid overload) and intervene immediately. Furthermore, client safety is maintained by strictly adhering to the legal scope of practice, which prohibits practical nurses from administering IV push medications.

Adım Adım Çözüm

1
Analyze the client's clinical context and the role of the practical nurse.
The client is receiving IV fluids, placing them at risk for fluid shifts. The practical nurse must monitor for complications, escalate critical findings, and stay strictly within their defined scope of practice.
Understanding the clinical risks dictates the appropriate and safe nursing actions.
2
Evaluate each option against established risk reduction principles and the practical nurse scope of practice.
Tachycardia, out-of-scope IV push medication orders, and fluid overload require immediate, specific actions. Delaying the reporting of hypokalemia, skipping barcode scans, and performing initial assessments violate safety standards.
Risk reduction requires strict adherence to safety protocols, rapid escalation of critical data, and knowing practice limitations.

Anahtar Kavram

Reduction of Risk Potential in Practical Nursing involves strict adherence to the scope of practice, diligent medication safety practices, and the prompt escalation of critical laboratory values and subtle changes in client condition.
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Reduction of Risk Potential

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