It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. c. Foot b. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. 2. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? & 4. This is an elderly client who is a new admit. Feedback There will likely be both physical and emotional injury that needs attention, which places this client third. Clients over the age of 65 must have a saline lock according to facility policy Elevating the head of the bed 30- 40 for the client post thoracotomy Which of the following actions should the nurse take? (Select all that apply.) 4. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. 3. Aplastic anemia is a rare but serious condition. Normally, red blood cells are flexible and round, moving easily through blood vessels. Which of the following interventions should the nurse include? b. A charge nurse is observing a group of newly licensed nurses. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. b. Invite staff to contribute ideas on scheduling changes. Which of the following findings should the nurse expect? The cleint's family asks the nurse for info about this type of care. Based on the information provided in report, which client condition should be the nurse's priority? b. 3. Review a low-sodium diet for a client with hypertension. 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. a. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). Speak to the UAP to determine what happened with the feeding. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. A charge nurse is planning client activities for the day. 3. It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. b. Place the pack on a sterile work surface b. 4. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). 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. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. What is the best first action for the nurse to take in order to achieve this goal? 2. Which of the following findings should the nurse identify as a safety risk? So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. 1. a. Auscultate breath should at least ever 2 hr Select all that apply. a. c. The nurse may serve as a witness to informed consent for organ donation A nurse asks a client to share personal stories. A nurse is caring for a client who has a hip fracture that requires surgical repair. So what is wrong with option #1? c. I will cover the catheter so he cannot see it Explain oral hygiene to a client receiving chemotherapy Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. December 5, 2020. 3. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. A nurse is assessing a client who has narcolepsy. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. 4. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. 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. The client states, "I'm feeling a bit nervous today." Correct: If suspicious behavior occurs, it is important to keep careful, objective records. 1., 2., 3., & 4. 1., 2., 3., & 4. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. 4. c. Changing a dressing 8. 2. 2. 2. Which of the following nontherapeutic communication techniques is the nurse using? Injuries from a motor-vehicle accident can be life threatening. a. 10. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. Read all the current literature related to oral care on unresponsive clients. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. Two nurses lifting the client under the shoulders Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A nurse is caring for a client who expresses anxiety about his impending surgery. Answer the following question to test your understanding of the preceding section: A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. d. Highly concentrated urine, 91. 1. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. c. Nonfat milk Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? c. Shivering A nurse is caring for a client who has a mental health disorder. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? & 3. 1. a. Clarifying The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. a. leadership management of care nurse on unit is providing care for group of clients. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Only the state Board of Nursing can legally determine the LPN's scope of practice. c. Providing anticipatory guidance to a client in crisis 4. Explore the client's feelings c. I'll bear weight on my ankle for 10 minutes every hour The third client that should be sent back for treatment is the female client stating she has been raped. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 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. A nurse is preparing to obtain a blood specimen from a client by venipuncture. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. a. Gloves c. Offering false reassurance b. 7. This should not be delegated to the LPN/LVN. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. 1. 2. d. I will place a bath seat in my shower to use when I bathe, b. Prepare a list of clients who could quickly be discharged or transferred. a. a. I will keep my walker at the end of my bed b. 4. Cardiac catheterization with a decreased pedal pulse below insertion site. Place the client in low Fowler's position Encourage clients and families to develop mutually appropriate visitation times. Client reporting epigastric pain and nausea after eating. Which of the following types of torts has the nurse committed? a. 5. This determination is needed to assure client safety is being considered. The nurse is focusing on which of the following elements of the communication process? Education Female client stating she has been raped. a. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 3. The charge nurse is planning the staff assignments for the clients on a neurological unit. Who should the nurse see first? The nurse should use close-ended questions when assessing which of the following factors? This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. c. Leave a nightlight on in the client's room Removing the abdominal dressing Temporary urinary retention (common for clients to develop after removal), 90. Encourage the client to be more cooperative. Temporary urinary retention Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. d. Determine if the client uses hearing aids, b. c. Inform the surgical team to cancel the client's surgery Which of the following responses should the nurse provide? Incorrect: Informing is the same thing as teaching. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". The nurse has just completed a 12 hour shift. b. Wash the tablet off with alcohol and place it in a clean medicine cup d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. Wears a gown when entering the room of a client who requires contact precautions assignmentcafe.com - A charge nurse is making assignments for nursing 2. A nurse asks a client how he is feeling. c. Include intact skin at the wound edges in the culture A client with exacerbation of COPD reporting dyspnea. Pernicious Anemia Society 5. b. I will begin once the client's discharge order is written The nurse does not know the skills of the new UAP. Besides, a charge nurse is a leader on the floor and should possess . 76. d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. Most of the following sentences contain errors in the use of modifiers and comparisons. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) 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. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. In which situation should the nurse consult the client's advanced directive? Because the charge nurse observes and weighs . A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. 4. 1. 4. -Review a low-sodium diet for a client who has HTN Collecting I & O totals for unit clients at the end of shift. The situation should be explored before bringing the supervisor in on the situation. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. A client post pacemaker insertion, awaiting discharge instructions. Provides day to day direction and supervision to assigneddirect patient care staff . Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. b. Irrigate the NG tube with 100 mL of sterile water which client would be an appropriate care assignment for this lpn? They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. D. The nurse asks why the client needs to know this. b. Client eating a simple-carb snack due to weakness. b. I will call the doctor and get the prescription A nurse is caring for a client who is postoperative following an appendectomy. c. Decreased sodium excretion Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. The nurse is using which of the following therapeutic communication techniques? It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. e. Throw rugs, 40. This client needs careful monitoring and specialized care. a. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. The nurse would then start the 24 hour urine once the 1st void has been discarded. a. Bathe a client who had an amputation 2 days ago A client requesting assistance packing his belongings for discharge later today.. 1. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. Select all that apply Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. a. There may be a good reason that the tray was not served. c. I'll wear low heeled shoes from now on d. Custard What is the best care assignment for this client? 3. The client must understand the need for restraints Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. Receive report from the emergency department (ED) on a new client. 4. A client with epilepsy reporting an odd smell in the room. the nurse responds: "It must be very frustrating to encounter this kind of attitude." 3. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Reach around the pack and open the top flap away from the body Remember, pick the killer answer first! 2. Incorrect: This would unnecessarily alarm the clients. c. One nurse lifting the client's legs as the client uses a trapeze bar Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) a. I'll sit with my knees lower than my hips is a new graduate in orientation. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. c. Changing a dressing, 78. Relax her abdominal muscles when she lifts an object A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Gather supplies to prepare room for isolation. Place the client in a lateral position Which of the following client statements indicates an understanding of the procedure? d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. Witness the client's signature d. I will begin once the client's insurance company approves discharge coverage, b. A charge nurse is making client care assignments. Encourage the client to use self-exploration Select all that apply. a. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. _____The house that we lived in for nine years has been sold. Although this will require assessment, this client is not the priority at this time. Did you recognize ureterolithiasis as "kidney stones"? The nurse voices his concern to the charge nurse. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 1. 3. The client is reporting anxiety, discomfort, and a feeling of bloating. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. 1. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. The client can indicate desire for Do Not Resuscitate (DNR). In order to reorganize staffing, the nurse manager should initiate which action first? The body needs vitamin B12 to make red blood cells. Make nursing assignments appropriate to the skill level . The client with chronic emphysema has expected shortness of breath. 4. 208 However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. b. I'll do exercises that strengthen my abdominal muscles A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Which of the following statements should the nurse identify as an indication the client needs further teaching? a. d. Talk with the client's partner, b. d. I shouldn't advice you about what is ultimately a personal decision, b. c. Open the right flap with the left hand - Assisting a client to ambulate using a gait belt. Channel Moistening the dentures prior to inserting them However, providing care for missing teeth would also be within the LPN scope of practice. Incorrect: Moistening the dentures will ease insertion. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? c. Palpating for pedal edema Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. 3. Correct. Ask the client to perform a return demonstration of insulin injection A nurse is caring for a client who is immobile. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. 1. Respite care allows the primary caregiver time away from day-to-day care responsibilities A nurse is administering a cold therapy application to a client. 3. The RN requests reassigning at least one of the clients to another nurse. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Client reporting a headache and has a fruity breath. 4. Where on the body is each type of skin found? Therefore, this client would not be a priority over a client who may be experiencing a MI. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29. 5. c. Hallucinations at the onset of sleep, 65. The report should contain consequences. Focus on the client's present circumstances instead of his personal stories Narrative interaction The surgeon initially prescribes a clear liquid diet. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Select all that apply. Briefly assess every client. In what order should the nurse assess assigned clients following shift report? The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. a. Broth 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. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? c. We administer all medications intravenously to clients in this unit A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. 1. This task cannot be delegated to the LPN/LVN. c. I will make sure my visitors smoke outside Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. The nurse should not be assigned to provide care if impairment is suspected. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. 2. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. 2. 2. Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47.
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