Editing Management of Care – LPN Practice Questions (section)

==Question 5==
A licensed practical nurse reports to the charge registered nurse that a client's blood pressure has dropped from 128/76 to 88/50 mm Hg and the client is now confused. The charge nurse says, "I am busy. I will get to it later." Which action should the LPN take '''next'''?
# Document that the charge nurse was notified and continue with the other assigned clients.
# Notify the nurse manager or house supervisor of the unresolved concern.
# Telephone the provider directly and request new orders.
# Wait and report the change during the end-of-shift handoff.

'''Answer:''' 2. Notify the nurse manager or house supervisor of the unresolved concern.

''Rationale:'' When a client safety concern is not addressed at one level, the nurse escalates to the next level of the chain of command, promptly and one step at a time, and documents each step. Options 1 and 4 leave a deteriorating client unassessed and expose the LPN to liability for failure to escalate. Option 3 skips a level of the nursing chain of command; the registered nurse is accountable for the assessment that must precede a call for new orders. The LPN's duty to the client is not discharged simply by having told someone once.