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Zorluk: KolayReduction of Risk Potential

A practical nurse is providing care for an adult client who is receiving intravenous (IV) fluids for the treatment of an acute gastrointestinal bleed. Which of the following actions should the nurse take to reduce the risk of complications and ensure client safety? Select all that apply.

  1. Inspect the client's stools and emesis for the presence of frank red blood or a coffee-ground appearance.Cevap
  2. B
    Delay reporting a hemoglobin level of 6.8 g/dL (68 g/L) until the end of the shift if the client is resting quietly.
  3. Verify the client's identity using two unique identifiers before administering any prescribed medications.Cevap
  4. D
    Document a new heart rate of 112 beats/min and blood pressure of 92/60 mm Hg as expected findings and continue routine monitoring.
  5. E
    Delegate the assessment of the client's peripheral perfusion and response to intravenous fluids to the unlicensed assistive personnel (UAP).
  6. Monitor the client's intravenous (IV) access site frequently for signs of infiltration, phlebitis, or bleeding.Cevap

Cevap

The correct actions are to inspect stools and emesis for blood, verify the client's identity before medication administration, and monitor the IV site frequently.
To effectively reduce the risk of complications, the practical nurse must prioritize fundamental safety protocols and vigilant clinical monitoring. Verifying client identity prevents medication errors. Inspecting stools and emesis for blood allows for the early detection of recurrent hemorrhage. Finally, frequent monitoring of the IV site ensures that emergency fluids or blood products can be administered rapidly and safely if the client's condition suddenly deteriorates.

Adım Adım Çözüm

1
Analyze the client's clinical situation and current risks.
The client is recovering from a gastrointestinal bleed and is receiving IV fluids, placing them at risk for recurrent hemorrhage, hypovolemic shock, localized IV complications, and medication errors.
Understanding the primary physiological and environmental risks allows the nurse to prioritize interventions that actively prevent complications.
2
Evaluate each nursing action for safety, effectiveness, and appropriate scope of practice.
Monitoring for bleeding, verifying identity, and checking IV patency are safe, appropriate actions within the practical nurse scope that actively reduce client risk.
These actions directly address the risk of medication errors, identify recurrent bleeding early, and ensure a safe route for emergency interventions.
3
Identify inappropriate or unsafe actions that increase client risk.
Delaying the report of a critically low hemoglobin level, ignoring early signs of shock, and delegating nursing assessments to UAP are unsafe actions.
These inappropriate actions violate safety protocols, delay life-saving medical interventions, and fall outside the legal scope of practice for delegation.

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Reduction of Risk Potential
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Reduction of Risk Potential

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