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Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is reviewing the care requirements for a group of assigned clients at the beginning of a shift. Which of the following planned actions demonstrate appropriate application of risk reduction principles within the PN scope of practice? Select all that apply.

  1. Pausing a continuous enteral tube feeding before placing a client in a supine position for a linen change.Cevap
  2. B
    Accepting primary care responsibility for a newly admitted client who requires initiation and titration of a continuous intravenous heparin infusion.
  3. C
    Administering a scheduled oral dose of potassium chloride to a client whose morning serum potassium level is reported as 6.1 mEq/L.
  4. Checking a client's most recent capillary blood glucose level prior to administering a scheduled dose of rapid-acting insulin.Cevap
  5. E
    Verifying a client's identity solely by checking the room number and bed assignment before administering a routine daily medication.
  6. F
    Documenting a subtle decrease in urine output and a heart rate increase from 82 to 108 beats/min as expected findings in a client with an active gastrointestinal bleed.

Cevap

The appropriate actions that demonstrate risk reduction within the PN scope are pausing a continuous enteral tube feeding before placing a client supine, and checking a client's capillary blood glucose level prior to administering rapid-acting insulin.
Risk reduction is successfully achieved when the practical nurse adheres to safety protocols and practices within their defined scope. Pausing enteral feedings before laying a client flat prevents regurgitation and aspiration pneumonia. Checking a blood glucose level before administering rapid-acting insulin is a critical safeguard required to prevent iatrogenic hypoglycemia.

Adım Adım Çözüm

1
Evaluate the risk of aspiration associated with continuous enteral feedings.
Pausing the feeding before laying the client flat is identified as a necessary action to prevent aspiration.
Maintaining the head of the bed elevated during and immediately after feedings uses gravity to keep stomach contents from refluxing.
2
Assess the PN scope of practice regarding intravenous therapy and patient assignments.
Accepting an assignment for a client requiring titration of continuous IV heparin is identified as an action outside the PN scope.
Titrating high-risk IV medications based on laboratory values requires the comprehensive assessment skills of a registered nurse.
3
Analyze laboratory values in relation to scheduled medications.
Administering additional potassium to a client with a serum level of 6.1 mEq/L is identified as unsafe.
A potassium level above 5.0 mEq/L is elevated; administering more potassium could cause fatal cardiac dysrhythmias.
4
Review the protocol for safe administration of high-alert medications like insulin.
Checking the blood glucose level prior to insulin administration is identified as a safe, required practice.
Insulin lowers blood sugar; administering it without knowing the current level risks inducing severe hypoglycemia.
5
Identify the standard requirements for safe client identification.
Using a room and bed number is identified as an unsafe client identification method.
Two unique, client-specific identifiers (such as name and date of birth) must be used to prevent medication errors.
6
Evaluate the clinical significance of vital sign trends in a client at risk for hemorrhage.
Dismissing tachycardia and decreased urine output in a bleeding client is identified as a dangerous failure to rescue.
These findings represent early compensatory mechanisms for hypovolemic shock and require immediate escalation rather than routine documentation.

Anahtar Kavram

Risk reduction involves practicing strictly within the established scope of practice, properly identifying clients using two unique identifiers, escalating critical laboratory and vital sign abnormalities, and performing procedural safeguards such as verifying blood glucose before insulin and preventing aspiration during enteral feeding.
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Reduction of Risk Potential

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