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Zorluk: Çok zorReduction of Risk Potential

A practical nurse is managing care for multiple clients on an acute medical-surgical unit. Which of the following independent or collaborative actions by the practical nurse demonstrate the correct application of risk reduction principles? Select all that apply.

  1. Questions a prescription to administer a continuous intravenous infusion of 0.45% sodium chloride to a client admitted with a severe traumatic brain injury.Cevap
  2. Withholds a scheduled oral dose of spironolactone and alerts the registered nurse upon noting a client's morning serum potassium level is 5.8 mEq/L.Cevap
  3. C
    Evaluates a client two hours after an open cholecystectomy, noting a steady heart rate of 118 beats per minute and blood pressure of 96/60 mmHg, and decides to recheck in four hours.
  4. D
    Reviews a serum calcium level of 6.8 mg/dL for a client 24 hours post-thyroidectomy and documents the result for the provider to address during afternoon rounds.
  5. E
    Accepts a client care assignment that involves continuous arterial line monitoring and the active titration of an intravenous labetalol infusion for hypertensive crisis.
  6. F
    Administers a scheduled oral antihypertensive medication without scanning the client's identification wristband because the client verbally stated their first name and is familiar to the nurse.

Cevap

The correct actions are questioning the hypotonic fluid prescription for the traumatic brain injury client, and withholding the potassium-sparing diuretic for the hyperkalemic client.
Effective risk reduction requires the practical nurse to synthesize pharmacology, pathology, and laboratory data to prevent harm. Questioning a hypotonic intravenous fluid in a traumatic brain injury prevents lethal exacerbation of cerebral edema. Withholding spironolactone, a potassium-sparing diuretic, in a client with an already elevated potassium level of 5.8 mEq/L prevents potentially fatal cardiac dysrhythmias.

Adım Adım Çözüm

1
Evaluate the fluid tonicity prescribed for the traumatic brain injury (TBI) client.
Identified that 0.45% sodium chloride is a hypotonic solution.
Hypotonic solutions cause fluid shifts into cells, increasing cerebral edema. Questioning this order prevents neurological deterioration.
2
Analyze the laboratory values against the prescribed medications.
Identified that the client has hyperkalemia (5.8 mEq/L) and is prescribed spironolactone.
Spironolactone retains potassium. Giving it would dangerously elevate potassium levels further, risking cardiac arrest. Withholding it is essential.
3
Review the remaining actions to identify breaches in risk reduction or scope of practice.
Identified that options involving delayed reporting of borderline shock, ignoring critical hypocalcemia, accepting a vasoactive drip assignment, and bypassing medication scanning are all unsafe.
Risk reduction requires immediate escalation of critical clinical changes, operating strictly within the legal scope of practice, and adhering to strict medication safety protocols.

Anahtar Kavram

Clinical Judgement and Risk Mitigation in the Practical Nurse Scope of Practice
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Konular

Reduction of Risk Potential

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