A licensed practical nurse (LPN) is planning care for an assigned adult client who was adm… — NCLEX-PN

A licensed practical nurse (LPN) is planning care for an assigned adult client who was admitted with acute pyelonephritis and has a history of chronic kidney disease. The client is receiving continuous intravenous fluids and scheduled antibiotics. Which of the following clinical decisions by the nurse demonstrate appropriate reduction of risk potential? Select all that apply.

Immediately notify the supervising registered nurse that the client's morning serum creatinine has increased from a baseline of $1.2\text{ mg/dL}$ to $2.6\text{ mg/dL}$ .Cevap
B
Administer the prescribed intravenous push ondansetron to treat the client's morning nausea and prevent potential aspiration.
Hold the scheduled oral potassium chloride supplement due to a morning serum potassium level of $5.3\text{ mEq/L}$ and alert the healthcare provider.Cevap
D
Document a morning blood pressure of $96/58\text{ mmHg}$ and a heart rate of $110\text{ bpm}$ as expected responses to infection, and recheck at the next scheduled interval.
Initiate strict measurement of fluid intake and output, and immediately report a cumulative urine volume of $60\text{ mL}$ over the previous $3\text{ hours}$ .Cevap
F
Detail the potential complications of an upcoming cystoscopy procedure to the client to verify full comprehension before witnessing the consent form.

Cevap

The correct clinical decisions involve notifying the RN about the increased serum creatinine, holding the potassium supplement for an elevated potassium level, and reporting the low urine output.

The correct actions focus on recognizing critical changes in the client's condition and acting strictly within the licensed practical nurse (LPN) scope of practice to mitigate patient harm. A sudden increase in serum creatinine indicates acute kidney injury, which requires immediate notification to the registered nurse (RN) to potentially adjust antibiotic dosages. A serum potassium of

5.3\text{ mEq/L}

is elevated (hyperkalemia), so holding scheduled potassium supplements prevents dangerous cardiac complications. Finally, a urine output of

60\text{ mL}

over

3\text{ hours}

yields a rate of

20\text{ mL/hr}

, falling significantly below the minimum adequate threshold of

30\text{ mL/hr}

. This oliguria suggests worsening renal perfusion or early shock and demands immediate escalation.

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Analyze the serum creatinine level.

The value increased from

1.2\text{ mg/dL}

2.6\text{ mg/dL}

This signifies an acute decline in kidney function which requires immediate escalation to adjust medication dosages and prevent toxicity.

Evaluate the serum potassium level.

The morning value is

5.3\text{ mEq/L}

, which is above the normal range of

3.5-5.0\text{ mEq/L}

Administering additional potassium would induce severe hyperkalemia, threatening cardiac stability; holding it mitigates this risk.

Calculate the hourly urine output rate.

A volume of

60\text{ mL}

over

3\text{ hours}

equates to

20\text{ mL/hr}

Normal minimum urine output is

30\text{ mL/hr}

. Values below this threshold in a client with a systemic infection strongly suggest impaired organ perfusion, necessitating emergency notification.

Anahtar Kavram

Evaluating clinical data to identify emerging complications and taking actions that remain within the LPN scope of practice to mitigate harm.

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