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Study guide · Physiological Integrity

Reduction of Risk Potential

8 to 14% of the exam · 19 activity statements

Reduction of Risk Potential is the practical nurse's work of keeping a condition, a test or a procedure from turning into harm: watching trends in vital signs and assessments, collecting specimens, running point-of-care tests, caring for urinary catheters, gastrointestinal tubes and peripheral IV lines, and preparing and teaching clients before and after procedures. REx-PN items test whether the practical nurse in British Columbia or Ontario measures correctly, recognizes the result or change that matters, acts within the PN's role and brings in the RN or primary health care provider when the client is unstable or the finding needs a new order.

A study feature written by ExamDragon, not part of the real exam. Each heading is one of the Related Activity Statements the Test Plan lists for this category (19 of them), in our words; the official wording is in the Test Plan.

At a glance

Physiological Integrity
8 to 14%

of the exam (the Test Plan's range)

Activity statements
19
Key terms
10

What this guide covers, statement by statement

  1. Notice when the client's condition shifts or trends and act on it
  2. Take precautions so a diagnosis or procedure does not lead to injury or complications
  3. Check vital signs and act when they shift or trend
  4. Carry out focused assessments
  5. Insert, care for or take out a urinary catheter
  6. Collect non-blood specimens, such as urine, stool or wound samples, for tests
  7. Follow test results and act on them
  8. Care for a client before surgery
  9. Judge how the client reacts to treatments and procedures and act on it
  10. Explain treatments and procedures to the client
  11. Look after or remove a nasogastric or orogastric tube
  12. Insert a nasogastric or orogastric tube
  13. Carry out bedside tests, such as bladder scans or point-of-care checks, and act on results
  14. Look after or take out a peripheral IV
  15. Start a peripheral IV
  16. Teach a client what to expect before or after surgery
  17. Care for someone recovering from a procedure under conscious sedation
  18. Look after a feeding tube placed through the skin
  19. Watch suction on a nasogastric tube, whether continuous or intermittent

1Notice when the client's condition shifts or trends and act on it

  • One reading is a snapshot; compare it with the client's own baseline and the last several readings before deciding what it means.
  • A slow drift (rising respiratory rate, falling urine output, new restlessness) often comes hours before a sudden event, so look for it on every round.
  • Act on what is within your role at once: reposition, apply prescribed oxygen, stop an infusion that is causing harm, recheck the measurement.
  • Report the trend, not only the last number, using a structured report such as SBAR to the RN or primary health care provider.
  • Use the facility's early warning or rapid response criteria; calling for help early is safe practice, not failure.
  1. In practiceA client two days after a bowel resection has a respiratory rate that went from 16 to 22 to 26 over eight hours, with a new heart rate of 112. The practical nurse raises the head of the bed, checks oxygen saturation, and reports the trend to the RN with the readings in order rather than waiting for the next scheduled check.
  2. Where questions turnTreating each reading as normal for that hour and missing a steady worsening across the shift.
Practise this activity

2Take precautions so a diagnosis or procedure does not lead to injury or complications

  • Know the complication a procedure or diagnosis carries and the precaution that prevents it: bleeding after a biopsy, aspiration with dysphagia, falls with sedation, contrast reactions.
  • Check allergies, anticoagulant use and kidney function before a procedure that uses contrast or carries a bleeding risk, and report concerns before it starts.
  • Keep the client in the position ordered after a procedure (flat after some punctures, side-lying after a liver biopsy) for the time ordered.
  • Bleeding precautions: soft toothbrush, electric razor, no intramuscular injections without checking, pressure on puncture sites for longer.
  • Seizure, aspiration and fall precautions are set up before the event, not after it.
  1. In practiceA client with a platelet count of 38 x 10^9/L (150 to 400) is to have blood drawn and a dressing changed. The practical nurse applies firm pressure longer after the draw, uses a soft toothbrush and electric razor in care, and handles tape gently on the skin.
  2. Where questions turnChoosing a comfort measure that causes the very complication the client is at risk for, such as an intramuscular injection with a low platelet count.
Practise this activity

3Check vital signs and act when they shift or trend

  • Measure correctly: the right cuff size (too small reads high), the arm at heart level, a full minute for an irregular pulse, a probe on a warm finger for oxygen saturation.
  • Interpret against the client's baseline and context: a blood pressure of 100/60 is fine for one client and a drop of 50 mmHg for another.
  • Hypotension with a rising heart rate suggests bleeding or fluid loss; rising blood pressure with a falling pulse and a changing level of consciousness suggests raised intracranial pressure.
  • Recheck a reading that does not fit the client before acting on it, unless the client looks unwell, in which case act and recheck together.
  • Mean arterial pressure is (systolic + 2 x diastolic) / 3; below about 65 mmHg organs may not be perfused.
  1. In practiceA client's blood pressure reads 168/94, well above her usual 130/80, and the standard adult cuff is too small for her large upper arm. The practical nurse knows a cuff that is too small reads high, rechecks with a large cuff, gets 138/82, records that reading and tells the RN about the first one. Had the client also had a new headache or blurred vision, the practical nurse would report at once while rechecking.
  2. Where questions turnActing on a reading taken with the wrong technique, or rechecking endlessly while a client with clear symptoms gets worse.
Practise this activity

4Carry out focused assessments

  • A focused assessment looks closely at the system the problem involves: neurovascular checks after a cast, lung sounds with dyspnea, bowel sounds and distension after abdominal surgery.
  • Neurovascular checks compare both limbs: colour, warmth, capillary refill, pulses, sensation, movement and pain.
  • Neurological checks include level of consciousness, orientation, pupils and limb strength; a falling level of consciousness is the earliest and most important change.
  • Use the same scale each time (pain 0 to 10, Glasgow Coma Scale) so changes can be compared.
  • The practical nurse performs focused assessments on stable clients and reports findings; a new or unstable finding goes to the RN or primary health care provider.
  1. In practiceA client with a new cast on the right forearm reports tingling in the fingers. The practical nurse compares capillary refill, colour, warmth and movement in both hands, finds the right fingers cool and pale with pain on passive stretch, elevates the arm to heart level and reports at once.
  2. Where questions turnAssessing only the affected limb, so there is no comparison to show what has changed.
Practise this activity

5Insert, care for or take out a urinary catheter

  • Insert a urinary catheter only with an order, using sterile technique and the smallest suitable size; stop and report if resistance does not ease.
  • Keep the drainage bag below the bladder and off the floor, the tubing free of kinks and the system closed.
  • Clean the meatus with soap and water in daily care; routine antiseptic cleaning and routine irrigation are not needed.
  • Review the need for the catheter every day; removing it early is the best way to prevent catheter-associated urinary tract infection.
  • After removal, track the time and volume of the first voids and watch for retention; a bladder scan helps when the client cannot void.
  1. In practiceA client's indwelling catheter is removed at 0600 as ordered. By 1200 the client has not voided, feels pressure above the pubic bone and the bladder scan shows 520 mL. The practical nurse reports to the primary health care provider for an order rather than waiting longer.
  2. Where questions turnHanging the drainage bag on the bed rail above the bladder or resting it on the floor.
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6Collect non-blood specimens, such as urine, stool or wound samples, for tests

  • Label every specimen at the bedside with two identifiers, and send it promptly or store it as the laboratory directs.
  • Midstream urine: clean the meatus, start voiding, then collect the middle of the stream in a sterile container.
  • From an indwelling catheter, clamp the tubing below the port briefly if needed and draw from the sampling port with a sterile syringe, never from the bag.
  • A 24-hour urine collection starts with the bladder emptied and that urine discarded, and ends with a final void collected at the same time the next day.
  • Wound cultures are taken from clean viable tissue after the wound is cleansed with saline, not from old drainage or pus on the dressing.
  1. In practiceA client needs a 24-hour urine collection starting at 0800. The practical nurse has the client void at 0800 and discards that urine, keeps all urine until 0800 the next day on ice or as directed, and collects a final void at 0800 to end it.
  2. Where questions turnKeeping the first void of a 24-hour collection, or taking a urine culture from the drainage bag.
Practise this activity

7Follow test results and act on them

  • Know the common reference ranges in SI units: potassium 3.5 to 5.0 mmol/L, sodium 135 to 145 mmol/L, fasting glucose about 4.0 to 6.0 mmol/L (7.0 or more fasting is the diagnostic threshold for diabetes; 4.0 to 7.0 is a common treatment target in diabetes), hemoglobin 120 to 160 g/L, platelets 150 to 400 x 10^9/L, white blood cells 4.0 to 11.0 x 10^9/L.
  • Read each result against the client: an INR of 2.5 is expected on warfarin and dangerous after surgery in a client not on an anticoagulant.
  • Hold or question a medication when a result makes it unsafe (low potassium with digoxin, high INR with warfarin) and report to the prescriber.
  • Critical values are reported promptly by the laboratory and by the nurse; document who was told and when.
  • A result that does not fit the client may be an error (a haemolysed sample); report it and ask about repeating it.
  1. In practiceA client on furosemide and digoxin has a morning potassium of 3.0 mmol/L (3.5 to 5.0). The practical nurse holds the digoxin until the prescriber is told, reports the result and asks about potassium replacement, and watches the client's heart rate and rhythm.
  2. Where questions turnGiving the scheduled medication first and reporting the result later.
Practise this activity

8Care for a client before surgery

  • Confirm the informed consent is signed before sedation is given; the surgeon obtains it, the nurse checks it and reports when the client has questions.
  • Follow the fasting order; tell the anaesthesia team if the client ate or drank.
  • Check allergies, identification band, ordered labs and vital signs, and remove jewellery, dentures, glasses and nail products as the facility directs.
  • Ask about anticoagulants, antiplatelets, herbal products and insulin; hold or give them only as ordered.
  • Have the client void before the preoperative medication and keep the bed low with rails as policy directs after it is given.
  1. In practiceA client scheduled for surgery at 1000 tells the practical nurse at 0700 that a family member brought coffee with cream at 0600. The practical nurse reports this to the RN and the surgical team before the client goes to the operating room.
  2. Where questions turnAssuming a small drink does not matter and not reporting a break in the fasting order.
Practise this activity

9Judge how the client reacts to treatments and procedures and act on it

  • Compare the client after a treatment with the client before it: oxygen saturation after a nebulizer, pain after repositioning, urine output after a fluid bolus.
  • Know the expected response and the warning signs for each treatment, and check at the time the response should appear.
  • Stop a treatment that is causing harm when that is within your role (stop a transfusion or an infusion) and report at once.
  • Document the response with a measurement, not only words such as tolerated well.
  • When the expected response is missing, report it so the plan can be changed.
  1. In practiceA client's oxygen saturation was 88% before a prescribed salbutamol nebulizer. Twenty minutes later it is 95% with fewer wheezes. The practical nurse records both readings and the lung sounds, and keeps watching for the heart rate rise salbutamol can cause.
  2. Where questions turnRecording that the client tolerated the treatment without measuring whether it worked.
Practise this activity

10Explain treatments and procedures to the client

  • Reinforce what the primary health care provider explained about a treatment or procedure; the provider explains risks and obtains consent.
  • Use plain language, small amounts at a time and the teach-back method to check understanding.
  • Tell the client what they will feel and what they must do (lie still, hold their breath, drink the contrast) so they can take part.
  • Teach the warning signs to report after a procedure and who to call.
  • When the client does not understand the procedure or the risks before signing, report it to the provider rather than explaining the risks yourself.
  1. In practiceA client going home with a cardiac event monitor asks what to do when symptoms happen. The practical nurse reinforces pressing the event button, noting what they were doing and how they felt, and keeping the device dry, then asks the client to show the steps back.
  2. Where questions turnExplaining the surgical risks to a client who has questions before signing consent instead of involving the surgeon.
Practise this activity

11Look after or remove a nasogastric or orogastric tube

  • Check the placement of a nasogastric tube before every use: the external length mark and the aspirate pH (gastric 5.5 or below as most policies set it); X-ray confirms first placement.
  • Flush with the volume of water ordered before and after medications and feeds to keep the tube open.
  • Secure the tube to the nose without pressure on the nostril, and give mouth and nose care often.
  • To remove: explain, raise the head of the bed, flush with air or water as policy directs, clamp or pinch the tube, have the client take a breath and hold it, and withdraw steadily.
  • After removal, watch for nausea, distension and vomiting, which may mean the gut is not ready.
  1. In practiceBefore giving medications through a nasogastric tube, the practical nurse sees the tube mark has moved from 55 cm to 61 cm at the nostril. The practical nurse does not use the tube and reports so placement can be confirmed.
  2. Where questions turnUsing the sound of air injected over the stomach to confirm placement.
Practise this activity

12Insert a nasogastric or orogastric tube

  • Measure the length from the tip of the nose to the earlobe and then to the xiphoid process, and mark it.
  • Sit the client upright with the head tilted forward as the tube passes the back of the throat, and have the client sip water and swallow if allowed.
  • Stop and pull back if the client coughs, cannot speak or becomes short of breath or cyanotic; the tube may be in the airway.
  • Confirm placement as policy requires (X-ray before the first feed or medication) and check the aspirate pH.
  • Never insert a nasal tube when the client has a basal skull fracture or recent facial trauma; report for another route.
  1. In practiceDuring nasogastric tube insertion the client begins to cough hard and cannot talk. The practical nurse withdraws the tube, lets the client recover and tries again only once the client is breathing comfortably.
  2. Where questions turnPushing on through coughing and gagging because the tube is almost at the mark.
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13Carry out bedside tests, such as bladder scans or point-of-care checks, and act on results

  • Point-of-care glucose: clean and dry the finger, use the side of the fingertip, wipe away the first drop if policy directs, and use a meter that passed its control check.
  • Hypoglycemia is a glucose below 4.0 mmol/L; treat a conscious client with 15 g of fast-acting carbohydrate and recheck in 15 minutes.
  • A bladder scan measures the urine left in the bladder; follow the order or protocol for when to catheterize.
  • Repeat a result that does not fit the client, and check the client, not only the number.
  • Record the result and what you did; report results outside the ordered range.
  1. In practiceA client with diabetes is sweaty and shaky before lunch. The point-of-care glucose is 3.2 mmol/L. The practical nurse gives 15 g of fast-acting carbohydrate, rechecks in 15 minutes and reports the episode.
  2. Where questions turnTesting a finger wet with alcohol or lotion and acting on a falsely high or low reading.
Practise this activity

14Look after or take out a peripheral IV

  • Assess the site every hour or as policy directs for a continuous infusion: redness, warmth, swelling, coolness, pain and leaking.
  • Infiltration: cool, pale, swollen site; phlebitis: red, warm, tender along the vein. In either case stop the infusion, remove the catheter and restart in another limb.
  • Flush a saline lock as policy directs to keep it open; never force a flush against resistance.
  • Change the dressing when it is wet, loose or soiled, and label it.
  • To remove: stop the infusion, remove the dressing, withdraw the catheter, apply pressure until bleeding stops, and check that the catheter tip is intact.
  1. In practiceA client's IV site in the left forearm is cool, puffy and pale, and the client says it feels tight. The practical nurse stops the infusion, removes the catheter, elevates the arm and restarts the IV in the other arm.
  2. Where questions turnFlushing harder or raising the bag to get an infiltrated IV running again.
Practise this activity

15Start a peripheral IV

  • In adults choose a forearm vein in the non-dominant arm, working from distal to proximal; avoid the antecubital fossa and other areas of flexion, injured areas and the arm on the side of a mastectomy or a dialysis fistula.
  • Use the smallest gauge that suits the therapy; a larger gauge is chosen for blood and rapid fluids.
  • Clean with the antiseptic policy names and let it dry; do not touch the site after cleaning.
  • Limit attempts as policy directs, then ask a colleague; each failed attempt uses up veins.
  • Insert peripheral IV lines only when it is within your individual competence and employer policy; otherwise involve the RN.
  1. In practiceA client who had a left mastectomy with lymph node removal needs a peripheral IV. The practical nurse chooses a vein in the right forearm and avoids the left arm completely.
  2. Where questions turnStarting in the antecubital fossa, which limits movement and rules out the veins below it, or making more attempts than policy allows.
Practise this activity

16Teach a client what to expect before or after surgery

  • Before surgery, reinforce deep breathing, coughing with the incision splinted, leg exercises and early walking.
  • Teach the pain scale used and to ask for pain relief before pain becomes severe.
  • Reinforce the fasting order and which medications to take or hold, as the surgeon or anaesthesia team gave them.
  • At discharge, reinforce incision care, activity limits, signs of infection or clotting, and when to call.
  • Use teach-back; a client who cannot repeat the plan needs more teaching before discharge.
  1. In practiceBefore abdominal surgery the practical nurse shows the client how to hold a pillow over the abdomen to cough, and how to use the incentive spirometer, then has the client show both.
  2. Where questions turnWaiting until after surgery, when pain and sedation make learning hard, to teach breathing exercises.
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17Care for someone recovering from a procedure under conscious sedation

  • Conscious sedation leaves the client drowsy but breathing on their own; the greatest risk afterward is respiratory depression.
  • Monitor level of consciousness, airway, respiratory rate, oxygen saturation, blood pressure and heart rate as often as the protocol requires until the client is back at baseline.
  • Keep the client on their side or with the head raised, side rails up as policy directs, suction and oxygen ready, and nothing by mouth until the gag reflex returns.
  • Know which reversal agent is available (naloxone for opioids, flumazenil for benzodiazepines) and call for help if breathing slows.
  • The client does not drive, sign legal papers or stay alone for the time the instructions give after discharge.
  1. In practiceThirty minutes after a colonoscopy with sedation, a client's respiratory rate is 8 and oxygen saturation 87%. The practical nurse tries to rouse the client, opens the airway, applies oxygen and calls for help immediately.
  2. Where questions turnGiving the client fluids before the gag reflex is back after a procedure involving the throat.
Practise this activity

18Look after a feeding tube placed through the skin

  • A gastrostomy or jejunostomy tube is checked before each use by the external length mark or the position of the external bumper.
  • Keep the head of the bed at 30 degrees or higher during feeds and for 30 to 60 minutes after.
  • Flush with water before and after each medication and feed, and give medications one at a time in liquid form or crushed if they can be crushed.
  • Clean the site daily with soap and water and keep it dry; watch for redness, leaking and granulation tissue.
  • A new tube that comes out is reported at once; the tract can close within hours.
  1. In practiceA client with a gastrostomy tube has a moist, red area around the site with some leaking gastric fluid. The practical nurse cleans and dries the skin, applies a dry dressing as ordered and reports the leaking.
  2. Where questions turnMixing several crushed medications together, or crushing an enteric-coated or extended-release tablet.
Practise this activity

19Watch suction on a nasogastric tube, whether continuous or intermittent

  • Set the suction at the pressure ordered, usually low and intermittent for a single-lumen tube; continuous low suction is used with a double-lumen sump tube.
  • Keep the air vent of a sump tube open and above the stomach, and never clamp it.
  • Measure and record the drainage, subtracting any irrigation fluid, and note its colour and consistency.
  • Watch for fluid and electrolyte loss: low potassium, metabolic alkalosis, low urine output.
  • When drainage stops and the client becomes nauseated or distended, check the tube and suction settings and irrigate only if ordered.
  1. In practiceA client on low intermittent suction stops draining and reports nausea with a distended abdomen. The practical nurse checks that the suction is on and the tubing is not kinked, then reports so irrigation can be ordered if the tube is blocked.
  2. Where questions turnCounting irrigation fluid as drainage, which overstates the client's losses.
Practise this activity

Key terms

Baseline
The client's usual values, used to judge whether a new reading is a change.
Critical value
A result so far from normal that it must be reported promptly.
Mean arterial pressure (MAP)
The average pressure that perfuses the organs: (systolic + 2 x diastolic) / 3.
Neurovascular check
Colour, warmth, capillary refill, pulses, sensation, movement and pain in a limb, compared with the other side.
Infiltration
IV fluid leaking into the tissue: a cool, pale, swollen site.
Phlebitis
Inflammation of a vein: redness, warmth and tenderness along it.
Point-of-care testing
A test done at the bedside, such as a capillary glucose or a urine dipstick.
Conscious sedation
Medication that leaves the client drowsy but able to breathe and respond, used for short procedures.
Sump tube
A double-lumen nasogastric tube with an air vent that allows continuous suction without damaging the stomach lining.
CAUTI
Catheter-associated urinary tract infection; prevented above all by removing catheters early.

After this guide: After this guide you should be able to recognize a worsening trend, carry out the PN's procedures for catheters, tubes, specimens and IV lines safely, and know when a finding goes to the RN or primary health care provider.

Practise Reduction of Risk Potential