The third client that should be sent back for treatment is the female client stating she has been raped. The charge nurse needs additional information to make a decision. b. Teach caregivers memory enhancement aids. 1. A nurse who is on hormone replacement therapy. A nurse has completed an informed consent form with a client. However, providing care for missing teeth would also be within the LPN scope of practice. The client attempted to climb over the side rails and fell A person can be designated to make medical decision in the event the client cannot. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. M2.4: Making Client Care Assignments-GECC As the RN charge nurse, you are preparing to make assignments for the oncoming shift on the medical- surgical unit. 2. An adolescent client post appendectomy reporting pain. 2. a. 4. 3. Select all that apply 2. b. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Try different methods of oral care on unresponsive clients to see what works best. The client with chronic emphysema has expected shortness of breath. Assign a nursing assistant to help the client with self-care activities. e. Throw rugs, 40. Aplastic Anemia Support Group. c. Open the right flap with the left hand Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? b. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. The area surrounding the insertion site feels warm to the touch a. The surgeon initially prescribes a clear liquid diet. 1. Obtain a bedside commode for the client's use The healthcare team should recognize the client as the center of the team. Which of the following client statements indicates an understanding of the procedure? 4. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. 55. 2. e. Suctioning a client's new tracheostomy tube, 93. Which of the following statements should the nurse make? Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. 4. b. 1. d. When asking if the client took his medications this morning, 82. All these clients have a GI problem. Remove all metal necklaces d. Services are centered in long-term care facilities, a. 1. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. 3. Serve food that have a hot/cold balance This stage is when testing occurs to identify boundaries of interpersonal behaviors Elderly client admitted 30 minutes ago with reports of constipation for four days. The nurse is planning care for a client admitted with Alzheimer's Disease. They are more direct when discussing issues Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. This client needs ongoing monitoring which is within the scope of practice for the LPN. d. Transporting a cerebrospinal fluid specimen to the lab Start MgSO4 at 3g/hr IV It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. (Select all that apply.). 3. c. Provide the client with a diet high in protein a. Perform the Heimlich maneuver a. A lack of rapid eye movement (REM) sleep Twist at the waist when she moves an object to one side Left upper forearm Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Performing passive range of motion (ROM) on the client with right sided paralysis. Which of the following instructions should the nurse include? 4. Which clients would be appropriate assignments for the LPN/LVN? Risperidone .5 mg PO daily b. Which of the following items should the nurse include on the lunch tray? Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. a. A nurse is providing care to a client who is on strict bed rest following surgery. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. c. There is fluid leaking around the insertion site Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Thus, the tasks involve successful management of the charge nurse's responsibilities. a. c. I should purchase a carbon monoxide detector for my home b. Wash the area of the puncture thoroughly with soap and water d. Lean back in the chair, b. 5. Client eating a simple-carb snack due to weakness. b. A client with COPD complaining of shortness of breath on exertion. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 3. This service focuses on teaching the primary caregiver to meet the client's needs A nurse is caring for a client who is postoperative following abdominal surgery. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? The client reports constipation for 4 days which may be an indication of worse problems. c. Check to see if the suction equipment is working Ask for any staff objections to rearranging work hours. 1., 2., & 5. 5. The nurse asks why the client needs to know this. a. What is the best care assignment for this client? 3. 1. A nurse is admitting a client from a long-term care facility. A cardiac step down unit has requested float staff because of multiple impending admissions. Administer tap water enemas until clear at 6 AM. The nurse is using which of the following therapeutic communication techniques? a. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? Correct: The client who has a cast and requires pain medication is a stable and predictable client. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. A home health nurse is conducting a home safety assessment for an older adult client. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. - Assisting a client to ambulate using a gait belt. Incorrect: The nurse is responsible for evaluating a client. The nurse should do this when repositioning is needed. b. 2. 2) Assist a client to ambulate using a gait belt. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? The spouse can rescind the Advance Directive if the client becomes unresponsive. The client asks about his medications and their effects. c. Review the client's progress toward personal objectives 3. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? a charge nurse is making client care assignments for the day. The RN with 5 years' experience in the Labor and Delivery unit. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. What action should the nurse take after mistakenly administering the wrong medication? c. Depression 3. B. b. c. Lock the medication in a room and finish preparing it after returning from the emergency Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? d. Voided 30 mL frequently A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. 2. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. They are likely to wait for others to initiate conversation 2. 3. which client would be most appropriate to assign a licensed practical nurse (lpn)? Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. When determining if the client is eating a well-balanced diet Remember airway, breathing and circulation (ABCs). Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. When a family member asks how respite care can help, which of the following responses should the nurse provide? 6. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. 1. During exacerbation, the client will have many diarrhea stools. Respite care allows the primary caregiver time away from day-to-day care responsibilities c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day The charge nurse is developing patient care assignments for the evening shift and needs to assign clients to a licensed practical nurse/licensed vocational nurse (LPN/LVN) and a certified nursing assistant (CNA). (Select all that apply) c. Explore the client's feelings about dietary modifications 3. 4. 1. d. I shouldn't advice you about what is ultimately a personal decision, b. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. 1. d. Talk with the client's partner, b. 3. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter Incorrect: Moistening the dentures will ease insertion. b. A nurse is caring for a client in the orientation phase of the nurse-client relationship. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. a. Reposition the client every 3 hr a. 3. Serve milk products separately from meals Incorrect: The nurse is responsible for monitoring a client. What is the most appropriate action by the charge nurse? Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). c. Leave a nightlight on in the client's room Furosemide 40 mg PO q.d. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 2. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. The nurse has been assigned four clients. Client who has multiple injuries from a motor vehicle accident. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". b. Dons gloves to empty a urinary drainage device Placing a washcloth in the bathroom sink prior to cleaning. Which of the following tasks should the charge nurse reassign to a licensed nurse? There are a total of 10 adult clients. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. Which tasks should the charge nurse delegate to the nursing assistant? 1. a. I'll sit with my knees lower than my hips Right forearm Client to receive dietary education. d. Explain oral hygiene to a client receiving chemo Obtain a client's consent Encourage clients and families to develop mutually appropriate visitation times. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. (SATA) -Bathing a client who had an amputation 2 days ago. Pain The best practice committee utilizes current research in their recommendations. a. d. Counting radial pulse a. For which of the following actions should the nurse intervene? 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. Correct. A nurse is caring for a client who is postoperative following an appendectomy. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." The situation should be explored before bringing the supervisor in on the situation. Which client would be appropriate for the RN to assign to the LPN? c. Palpating for pedal edema a. This would be out of the UAP's scope of practice. 4. The client can indicate desire for Do Not Resuscitate (DNR). There may be a good reason that the tray was not served. The last client would be the one needing dietary education. Administer sodium polystyrene sulfonate enema. c. Distended bladder A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following actions by the nurse is considered an indirect nursing care activity? 1. Suggest splitting the shift with another nurse. Provide an adaptive feeding device for the client, 50. The RN with 2 weeks' experience on the postpartum unit. A nurse is assessing a client at a follow-up clinic for acute low back pain. 3. 3. Which response by the LPN is appropriate in response to the inappropriate delegation? Assist a client to ambulate using a gait belt. Incorrect: It is out of the UAP's scope of practice to administer medication. Point out inconsistences in the client's behavior 4. This is an appropriate prescription. c. Offering false reassurance Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? 4. Which of the following actions should the nurse take? Discuss the assignment with another LPN. Request a prescription for a medication to ease the client's anxiety c. Notify the nurse manager What is the major histological difference between thick and thin skin? d. Social conversation, a. 1. A nurse is assessing a client who is experiencing prostatic hypertrophy. Transfer essential medical record to the receiving facility. Phone report to the receiving nurse. 5. b. Incorrect: Informing is the same thing as teaching. The client is getting better. 3. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. a. I will keep spare crutch tips handy Temporary urinary retention (common for clients to develop after removal), 90. It's unfortunate that I have to be in the hospital for this treatment 1. The nurse is using which level of communication at this time? The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. Who should the nurse see first? 1. A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. This client will also need a lot of education regarding anti-rejection medications. Although this will require assessment, this client is not the priority at this time. b. Select all that apply. The nurse is focusing on which of the following elements of the communication process? c. Do not eat or drink anything the morning of the test Four clients arrive for their appointment at a diabetic clinic. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. What action should the nurse implement first to ensure client safety? If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. In what order should the nurse see the clients? b. Which of the following interventions should the nurse include? 4. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. A nurse is assessing a client who has narcolepsy. 3. Correct: The medical nurse can be assigned to this client. Each ROM movement should be repeated 5 times during the session. b. Urinary frequency for several days c. Document in the client's medical record that she completed an incident report b. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Decreased or suppressed respiration are priority. 1. This individual should be provided appropriate comments of appreciation for this accomplishment. 2. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. c. Industry vs inferiority Draining the colostomy bag on a client with diarrhea. Soaking the dentures in hot water The client then states, "I have changed my mind and do not want to have the procedure done." Warm the feeding solution to the body temperature (Select all that apply.) 5. A charge nurse is making client care assignments. A nurse is planning care for a female client who has an indwelling urinary catheter. Thoracentesis reporting shortness of breath. Involve the client in their plan of care. c. I will place an area rug at the entry of my bathroom 5. c. Washes and rinses her hands for 10 seconds, 11. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Which of the following statements should the nurse identify as an indication the client needs further teaching? a. 4. -Review a low-sodium diet for a client who has HTN Feedback 3. This would be out of the UAP's scope of practice. c. Hallucinations at the onset of sleep, 65. Nothing will get passed the complete blockage. c. They tend to use more verbal communication 4. 4. Speak to the UAP to determine what happened with the feeding. 4. Oral surgeon d. Water heater temp 54.4 C (130 F) Ask the client to perform a return demonstration of insulin injection A nurse is engaging in relationship counseling with a male client. The women's health charge nurse is making assignments for the next shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. (Select all that apply.) A nurse is implementing direct nursing care for a group of clients in an acute care facility. A nurse is caring for a client who frequently attempts to remove his IV catheter. 5. Return any fresh linen not used for a client to the linen supply area Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. 1. This is likely cholelithiasis, which will need to be checked out. It would not be appropriate to overload this new employee with extra work. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. d. Reflection, c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation), 37. c. Helping the client into the shower Write the letter of your choice on the answer line. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. One important aspect is encouraging the flow of ideas between management and staff members. Gather and apply dressings to open wounds. 4. c. Assist the client to the floor and begin mouth-to-mouth The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Monitor for GI upset 30 minutes after meals. 1. 4. Feed the client after warming the food. Compartment syndrome could be developing which can impede circulation and cause nerve damage. c. imaginary Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. a. A nurse asks a client how he is feeling. d. Reduced blood viscosity, a. Auscultating heart sounds Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Besides yourself, there are the following staff: Your unit has 12 beds. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. 2. Which of the following findings indicates that the client is meeting this goal? Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. 6. Correct: Did you notice the hint? 3. 1. But the client does need to be assessed prior to the client with Crohn's disease who is improving. 3. a. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The nurse received a client following surgery 8 hours ago. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. The expected standard of care was strict bed rest), 96. a. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. 1. To which of the following rooms should the nurse assign the client? Gown The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). 2. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. The client would develop severe cramping. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 1. Asking for an explanation A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. Places the soiled linen in the floor before bagging it A nurse is orienting a new assistive personal (AP) to the unit. A client post pacemaker insertion, awaiting discharge instructions. 3. Incorrect: This again is assessment which is the role of the RN only. Wrapping the dentures in tissue while the client sleeps a. Sudden attacks of sleep A nurse wants to find out a better way to perform oral care on unresponsive clients. Which group of clients should she assign to the medical surgical nurse? Documentation is a communication tool for the interprofessional health care team. d. Remove and reinsert the NG tube, a. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Triage and assign color-coded tags to each client. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. a. Which of the following responses should the nurse make? Call the family of a client suffering from dementia to discuss long term care placement. Also, making a surgical bed for the client returning from surgery is a basic procedure. 3. a. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. Correct: The UAP can remind the client to do something that has already been taught by the nurse. Which of the following is the priority action by the nurse? UAPs can assist with elimination and are taught how to measure output. b. The charge nurse must triage and assign clients to appropriate staff. Limit the client's fluid intake in the evening Which of the following explanations should the nurse provide? The nurse cannot assign assessment and evaluation of the nursing process to the UAP. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. c. Face shield Perform range of motion (ROM) exercises at least 2-3 times daily Dr. Frankenstein had seen himself as a(n) ?\underline{? d. Message, 67. Richied5864 Richied5864 . An Advance Directive includes a Living Will and a Medical Power of Attorney. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Determine caregiver's stress level and coping strategies. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. This action is a defensive intervention, and does not address the quarrelsome behavior. Which of the following statements by the student indicates understanding of the discussion? (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 (Select all that apply.) This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. 3. b. c. Use an aggressive tone of voice However, there are some basic points which are standard among all facilities. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. 2. Alcoholic Anonymous Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Refuse the overtime assignment, being prepared for disciplinary action. The reason for the UAP not feeding the client needs to be determined. d. Remove tea and coffee from meal trays, b. 3. Which of the following statements should the nurse identify as an indication that the client requires further clarification? b. Incorrect: The charge nurse does not have to assess every client. Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. Showing disapproval Elderly clients have special fluid and electrolyte issues after a fall. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client. A nurse is caring for an older client who is at risk for skin breakdown. d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. b. Assess the client c. We administer all medications intravenously to clients in this unit A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. 1., 4., & 5. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. Two hours . d. Left forearm, b. d. Highly concentrated urine, 91. Which of the following responses should the nurse make? Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 2. b. I'll do exercises that strengthen my abdominal muscles A nurse is filling out an incident report after finding a client lying on the floor. Discuss the issue with the leader of the "best practices" committee. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. boston police most wanted list, purina antlermax bulk,