The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

Choice A reason: Administering an intramuscular injection is within the LPN’s scope of practice, ensuring safe delegation. This aligns with nursing delegation guidelines, making it the correct example of appropriate task assignment for the nurse to delegate to the LPN on a busy unit.

Choice B reason: Assessing a wound for infection requires RN judgment, exceeding the LPN’s scope. Administering an injection is appropriate, making this incorrect, as it’s an improper delegation compared to the nurse’s choice of a task within the LPN’s role.

Choice C reason: MAs cannot discuss test results, as this requires clinical judgment beyond their scope. LPN injection administration is correct, making this incorrect, as it’s an inappropriate task for the MA compared to the nurse’s proper delegation choice.

Choice D reason: Inserting a nasogastric tube is an RN task, not within the MA’s scope. LPN injection administration is appropriate, making this incorrect, as it’s unsafe delegation compared to the nurse’s selection of a task suitable for the LPN.