Reduction of Risk Potential Study Guide for the NCLEX-PN Exam

General Information

Of course, you’ll want to do everything you can to reduce risk to the client, other co-workers, and yourself during your work as an LPN. Here’s an outline of the major topics covered in this area on the NCLEX-PN® test. It includes things like spotting irregularities in lab reports and watching for complications after procedures. About 9% to 15% of the questions on the test concern this area of nursing, so if you’re still unsure about any of it, be sure to seek additional information sources.

Obtaining and Using Data

Vital Signs

One of the most basic data elements for client care is the client’s vital signs. These normally include pulse, blood pressure, respiratory rate, and pulse oximetry.

Check and Monitor

The LPN will frequently check and monitor a client’s vital signs. The frequency for checking vital signs is dependent on the client’s current status. For example, a stable client may only need one set of vitals during an eight-hour shift. However, a more critical client may have a requirement for collecting a set of vital signs every 15 minutes.

Compare

When vital signs are collected, the LPN should determine if they are in-range or out-of-range for the client’s age. For example, a systolic blood pressure reading over 120 mmHg is typically considered high. However, more important than comparison to the standard range is comparison to the client’s baseline. For example, if the client’s blood pressure has consistently been over 120 mmHg with no symptoms, this may be in-range for the client.

Teach the Client

The LPN should also reinforce client teaching regarding normal and abnormal vital signs, especially if the client is preparing for discharge. If the client has a history of hypertension, he or she may need to monitor his or her blood pressure at home and treat as needed. Additionally, certain clients may need to monitor for tachypnea (fast breathing), bradycardia (slow heart rate), or fever (high temperature).

Laboratory Values

Clients in the hospital may frequently have laboratory tests ordered and performed. The resulting values may indicate disease progression or a change in the client’s status. Therefore, it is important that the LPN both obtain and use these values during client care.

Knowledge

The LPN should be able to identify laboratory values as in-range or out-of-range. Additionally, abnormal lab values may indicate either a decline or improvement in the client’s condition.

ABGs (\(pH\), \(PO_2\), \(PCO_2\), \(SaO_2\), \(HCO_3\)) — Arterial blood gas (ABG) samples are frequently collected to test the arterial blood for pH level, saturation of oxygen and carbon dioxide, and bicarbonate. The standard ranges are:

\(pH\) 7.35–7.45
\(PaO_2\) 75–100 mmHg
\(PaCO_2\) 35–45 mmHg
\(O_2\) 94–100%
\(HCO_3\) 22–26 mEq/L

BUN— Blood urea nitrogen (BUN) tests for the amount of urea in the blood. When the body breaks down proteins, it creates ammonia, which is converted to urea in the liver, and urea is excreted by the kidneys. Therefore, BUN is an indirect test of liver function and kidney impairment. The normal range is 7–20 mg/dL.

cholesterol (total)— Cholesterol is a lipid found in the body. It is created in the liver and small intestine and transported by lipoproteins, such as low-density lipoproteins (LDL) and high-density lipoproteins (HDL). The normal range for total cholesterol is below 200 mg/dL

glucose— Glucose is a sugar carbohydrate found in the bloodstream. Glucose levels naturally rise after meals, and the pancreas secretes insulin to regulate glucose. It is commonly used in monitoring clients with diabetes. The normal range is 70–140 mg/dL.

hematocrit— is a measure of the percentage of red blood cells (RBCs) in the bloodstream. The normal value for males is 40%–52%, and the normal value for females is 36%–47%. Hematocrit may be tested to determine anemia, bleeding disorders, or fluid imbalance.

hemoglobin— Hemoglobin contains iron and is the main protein of RBCs. Hemoglobin measures the ability of the RBCs to carry oxygen. The normal range for males is 13.5–17.5 g/dL, and the normal range for females is 12–15.5 g/dL.

glycosylated hemoglobin (HgbA1C)— Glycosylated hemoglobin (HgbA1C) is a combination of glucose and hemoglobin. When the glucose level is elevated, the HgbA1C level will also be elevated, and testing HgbA1C can test for a history of blood sugar control. The normal range is 4%–5.9%.

platelets— Platelets, or thrombocytes, are the smallest type of blood cell, and they are responsible for clotting. Low platelet levels may indicate an increased risk for bleeding, and high levels may indicate an increased risk for clots. The normal range for platelets is 150,000–400,000 cells/mcL.

potassium— Potassium is an abundant electrolyte in the body. It plays a role in acid-base equilibrium along with transmitting electrical impulses in muscles. It is often tested when there are electrolyte imbalances and/or cardiac arrhythmias. The normal range is 3.5–5 mmol/L.

sodium— Sodium is an abundant electrolyte in the extracellular fluid. It plays a role in regulating fluid and electrolyte balance along with blood pressure regulation. The normal range is 135–145 mmol/L.

white blood cells (WBC)— White blood cells, also known as leukocytes, are created in the bone marrow and protect the body against infections. High levels of white blood cells may indicate an infection. The normal range is 4,000–10,000 cells/mcL.

creatinine— Creatinine is a byproduct of the metabolism of creatine, and it is excreted by the kidneys. Creatinine is routinely ordered when evaluating renal disease. The normal range for creatinine is 0.8–1.3 mg/dL.

prothrombin time (PT)— PT is a measure of how long it takes the blood to clot by testing five different clotting factors. This test can be useful when evaluating responses to medications used to prevent blood clots. The normal range is 11–13.5 seconds.

partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT)— PTT and aPTT are measures of how long it takes a fibrin clot to form. These tests are useful in titrating a client’s heparin dosage. The normal range for PTT is 60–70 seconds, and the normal range for aPTT is 25–40 seconds.

international normalized ratio (INR)— INR provides a standard result for prothrombin time tests regardless of how the sample was collected. This can be useful when looking into bleeding disorders or monitoring the client’s response to Coumadin® (warfarin). The normal range is 0.9–1.2 for clients not on antithrombotic medications. An INR between 2-3 is considered therapeutic for clients taking Coumadin.

Actions

When caring for clients who have lab tests ordered, the LPN may be involved in the collection of blood or other fluids for the tests as well as receiving the results.

Monitor

As with all clients, the LPN should monitor the client undergoing diagnostic or laboratory tests and promptly review the results. In many cases, the laboratory tests have been ordered because the client is symptomatic, and these symptoms may need to be managed prior to the results being available.

Compare

When the lab results are available, the client’s values should be compared to normal laboratory values. The LPN should note any abnormal values (high or low) and special consideration may need to be taken if any medications or disease processes may be the cause of those values.

Notify

If the client has abnormal lab test results, the primary healthcare provider should be notified. The primary healthcare provider may order an immediate repeat of the test to rule out a problem with the sample itself, such as lysis of cells.

Procedures

The LPN should reinforce client teaching on the purpose of lab tests that have been ordered. In particular, if a lab test requires the client to fast, the LPN should explain why this is important. Additionally, the LPN may be asked to perform the following tests:

venipuncture for blood draws— For most outpatient clients, when lab tests are ordered, the client will require a venipuncture to collect the blood for testing. The LPN should ensure that the proper tubes are available prior to performing this task, as different tests require different types/colors of tubes.

blood glucose monitoring— Many clients, especially pre-diabetic or diabetic clients, will require regular glucose monitoring. This is typically done using a finger prick and a handheld glucometer, as it only requires a small amount of blood.

specimen for diagnostic testing— In addition to blood tests, the LPN may be asked to collect urine, stool, or sputum for diagnostic testing. Routine protocol should be followed, and special steps may need to be taken for specimens like a “clean catch” urine sample.

Please note that the above tests may not be in the scope of LPN practice in every state. The overall national standard allows LPNs to perform these tasks; however, specific states may narrow the LPN’s scope of practice and these may not be part of their legal regulations.

Diagnostic Tests

While caring for clients, the LPN may be asked to administer certain diagnostic tests. These include, but are not limited to, electrocardiograms and occult blood tests.

Perform Electrocardiogram

An electrocardiogram (ECG or EKG) is a diagnostic test that measures the electrical activity of the heart. To perform this test, leads are placed on specific areas of the chest and extremities and connected to a monitor. The monitor traces the impulses of electrical activity and the result is a measurable EKG strip. The EKG is used to detect cardiac arrhythmias by looking for patterns, additions, or prolonged periods between certain segments of the PQRST waveform.

Perform Other Diagnostic Testing

Additionally, the LPN may be asked to perform other diagnostic testing. This may be done during routine care. For example, oxygen saturation is typically measured with every set of vital signs collected.

blood glucose— Blood glucose testing may be done occasionally for routine monitoring or may be done frequently for clients with diabetes.. Blood glucose testing can help determine the appropriate dose of insulin to deliver to a diabetic client.

oxygen saturation— Oxygen saturation, also known as pulse oximetry or pulse ox, measures the saturation of oxygen in the blood. This is typically performed using a finger probe that is non-invasive, and it is usually included in routine sets of vital signs.

occult blood— Occult blood tests are performed using a stool sample to test for blood in feces. This may be performed to investigate an internal bleeding disorder or may be performed on an annual basis to screen for colon cancer.

Educate Client

When the client has laboratory or diagnostic tests ordered, it is important for the nurse to reinforce client teaching about the purpose of and collection method for the test. The client may be anxious about these tests and may benefit from an explanation to alleviate any concerns.