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Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is reviewing the care plan for an older adult client who is admitted with an acute exacerbation of heart failure. Which of the following actions should the PN take to reduce the risk of potential complications? (Select all that apply.)

  1. Report a heart rate of 112 beats per minute and new-onset restlessness to the registered nurse.Cevap
  2. B
    Document a morning serum potassium level of 2.9 mEq/L in the chart without reporting it, as the client takes daily diuretics.
  3. Place the call light within the client's reach and instruct them to ask for assistance before standing up.Cevap
  4. D
    Bypass the scanning of the client's identification bracelet before giving oral medications because the PN recognizes the client from the previous shift.
  5. E
    Accept the task of administering a scheduled dose of intravenous (IV) push furosemide to expedite the client's treatment.
  6. Notify the registered nurse immediately if the client's blood pressure drops to 86/54 mm Hg.Cevap

Cevap

The correct actions are to report the elevated heart rate with restlessness, place the call light within reach to prevent falls, and notify the RN of the low blood pressure.
The practical nurse plays a vital role in reducing risk by promptly identifying and escalating early signs of complications. Tachycardia and restlessness can be early indicators of decreased cardiac output or hypoxemia, while a blood pressure of 86/54 mm Hg indicates severe hypotension requiring immediate RN notification. Additionally, implementing fall precautions by keeping the call light within reach minimizes the risk of injury, which is especially important for clients who may experience orthostatic changes from diuretic therapy.

Adım Adım Çözüm

1
Analyze the scope of practice for a practical nurse regarding medication administration and task delegation.
The PN must not administer IV push medications, as this requires RN-level assessment.
Accepting tasks outside the PN scope of practice increases the risk of patient harm.
2
Evaluate the clinical findings and laboratory data presented in the scenario.
A heart rate of 112 beats/min with restlessness, a blood pressure of 86/54 mm Hg, and a potassium level of 2.9 mEq/L are all highly abnormal findings.
These findings indicate potential complications such as early shock, hypoxemia, or a high risk for life-threatening dysrhythmias.
3
Determine the appropriate nursing interventions for the abnormal findings.
The PN must immediately escalate the abnormal vital signs and the critical potassium level to the RN or provider.
While the PN collects vital data, rapid escalation is required to ensure timely medical or RN intervention.
4
Assess the routine safety actions described in the options.
The PN must consistently verify two client identifiers before medication administration and implement strict fall precautions.
Skipping identification checks or failing to provide safety instructions directly violates risk reduction protocols.

Anahtar Kavram

Reduction of Risk Potential in Heart Failure Management
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Konular

Reduction of Risk Potential

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