Nurse B has been an RN for almost 20 years. One night, there is an unusually heavy caseload at the emergency care facility where she works. One patient at the facility is 32 years of age and presented with dehydration and heat stroke. The patient is showing signs of altered consciousness and has a rapid heartbeat and low blood pressure. Nurse B is one of two RNs on duty, so the task of starting the patient on a 0.9% normal saline IV has fallen to Nurse W, an LPN who began administering intravenous therapies approximately two weeks ago. With the initial assessment and plan of care complete, Nurse B decides to leave Nurse W to start the rehydration drip unsupervised because he seems confident in his ability to administer IV fluids; this frees her up to assist patients with multiple trauma. Although Nurse B has not personally supervised Nurse W during IV administration, she knows that this LPN is quite competent in other nursing tasks. When Nurse W offered to administer the saline, he confirmed that he has completed a Board-approved IV therapy course pursuant to ORC 4723.17. Additionally, Nurse B states that she will check back soon, and if any problems should arise, that she is to be notified immediately.

Nurse A is an RN, 37 years of age, working in a busy university hospital's cardiac intensive care unit who possesses a good deal of first-hand experience monitoring anticoagulant therapies. An obese male patient, 65 years of age, is admitted early in the morning with acute bilateral deep vein thrombosis in his femoral veins, confirmed by ultrasonography; the patient has a history of chronic heart failure, and his international normalized ratio (INR) is 0.5.

Attending Physician G, an intern, has ordered the patient to be started on an initial dose of warfarin 5 mg and enoxaparin. The patient care plan involves daily monitoring of INR and possibly titrating the warfarin dose to achieve a therapeutic INR of 2.5. For three days the patient's INR has been rising slowly to 1.5 on dosages of 7.5 mg and then 10 mg of warfarin. When Nurse A arrives for her shift after her day off (on day 5 of the patient's treatment), she discovers that in an attempt to speed the therapy, the intern has titrated the warfarin to 20 mg and the patient's INR is at 2.4. She knows from experience that warfarin dosages of 10 mg for heavier patients are acceptable, but 20 mg seems to be an overly aggressive approach, considering a peak effect of 36 to 48 hours, so she decides to ask Physician G to reduce the dosage back to 10 mg or to discontinue use. The physician admits not having experience administering anticoagulants and agrees to lower the dose to 5 mg.