Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. b. Correct: The client has the right to be involved in the decision making of their care. The client with cystitis is stable and has a predictable outcome. Which clients should be assigned to the CNA? The nurse does not know the skills of the new UAP. The cause of the fall may be cardiac, but the question does not indicate this. Although this will require assessment, this client is not the priority at this time. b. I will begin once the client's discharge order is written Teaching insulin self administration cannot be delegated to the LPN. (Select all that apply.) A nurse is caring for a client who has a mental health disorder. 2. A nurse enters an older adult client's room to insert a saline lock. 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 talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following client statements should indicate to the nurse the need for additional teaching? Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? d. Remove tea and coffee from meal trays, b. Sudden attacks of sleep Client to receive dietary education. Oral surgeon Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. The nurse should not lecture, scold or argue with the float nurse. 3. d. Go to employee health services, b. Sit side-by-side with the client A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. The RN with 2 weeks' experience on the postpartum unit. c. Environment Incorrect: There are situations in which the LPN must notify the primary healthcare provider. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. b. Irrigate the wound with an antiseptic prior to obtaining the specimen Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Remember, pick the killer answer first! a.) Which of the following types of communication breakdown does this response represent? A client requesting assistance packing his belongings for discharge later today., a. I'll apply ankle to my ankle today and tomorrow b. Assigning tasks to an AP This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 2. e. Feed a client who had a stroke 3 months ago, 31. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Elderly client who fell and fractured the left femoral neck. b. The situation should be explored before bringing the supervisor in on the situation. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. A nurse is adhering to standard precautions while caring for a group of clients. Sudden attacks of sleep Gather supplies to prepare room for isolation. Photo comes from the Greek word for light. b. 3. Client with ureterolithiasis who requires frequent PRN pain medication. Most of the following sentences contain errors in the use of modifiers and comparisons. 3. It's just not the right time for me to do this Select all that apply 3. Which of the following actions should the nurse take prior to administering the tube feeding? 3. Which of the following actions should the nurse perform when opening the sterile pack? 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. c. Leave a nightlight on in the client's room The option does not say the client is terminal, in a vegetative state, or in a coma. 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. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 4. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Reach around the pack and open the top flap away from the body 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. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Incorrect: Medications are not transferred with the client to a new facility. a. 4. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. a. 55. Lumbar puncture reporting a headache. "The client is weak on the right side, so please assist the client with dressing . b. Ask client if they are eating small, frequent meals. a. Gloves There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. It would not be appropriate to overload this new employee with extra work. 1. A nurse is caring for an older client who is at risk for skin breakdown. Besides, a charge nurse is a leader on the floor and should possess . b. Negligence Discuss the assignment with another LPN. 4. The nurse has just completed a 12 hour shift. UAPs can assist with elimination and are taught how to measure output. b. d. Providing information, a. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. Female client stating she has been raped. Client diagnosed with Guillain-Barre' who is receiving ventilator support. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. 1. A nurse has just finished a wound irrigation for a client who requires contact precautions. Serve milk products separately from meals 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. 2. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). b. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. A nurse is discussing the norming stage of the group development process with a student nurse. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? They have found my address and are coming for my family!" Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 3. c. Document in the client's medical record that she completed an incident report Assist a client to ambulate using a gait belt. 3. The client asks about his medications and their effects. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? These are appropriate tasks for an UAP to complete. Which of the following communication techniques should the nurse use during this phase? A nurse is teaching a client about carbon monoxide poisoning. b. Dons gloves to empty a urinary drainage device 3. 2. An experienced person who can research "best practice" regarding the issue is needed. a. Which of the following is the priority action by the nurse? 4. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Incorrect: This prescription is written correctly. a. The last client would be the one needing dietary education. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. c. Depression b. 5. 4. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 3. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. 3. Nurses Report Sheet Template Nicu. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. A nurse is caring for a client who states, "I have got to get out of this hospital! 4. This is a diabetic clinic. Obtain a client's consent Incorrect: What seems to be going on with this client? An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 1. a. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. A high concentration of carbon monoxide can cause death It is not a routine task. A school-aged child with a fractured femur who is in balanced suspension traction. The infusion rate has stopped but the tubing is not kinked 4. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. When the licensed person cannot determine this, the task should not be delegated. 3. 1. 3. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. 1. 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. 3. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. Pernicious Anemia Society a. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. (Select all that apply) b. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 6. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. c. Physical therapist 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. 3. b. There is a trailing zero after the prescribed dose. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain Focus on the client's present circumstances instead of his personal stories The nurse should perform which of the following activities in this space? Fruity breath. It's unfortunate that I have to be in the hospital for this treatment If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. c. Blood-tinged urine e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. A nurse is developing a plan of care for a client who practices Islam. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). c. Holds the soiled linen against her body while carrying it to the linen bag 2. Which of the following actions should the nurse take? 4. The report should contain consequences. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. Incorrect: This client does not have a predictable outcome. 3. Schedule visiting times in two-hour increments so clients are not overwhelmed. b. d. Talk with the client's partner, b. }? benefactor of the world. They are able to manage tasks related to basic care. 3. Which of the following statements should the nurse make? a. Incorrect: Moistening the dentures will ease insertion. It contains a blank and is followed by four answer choices. Involve the client in their plan of care. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. A nurse is preparing to obtain a blood specimen from a client by venipuncture. 5. 3. b. b. a. d. Droplet, d. Bend at the knees when picking up an object, 98. 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. Removing the abdominal dressing Write N next to the nonessential clauses and E next to the essential clauses. *HURST REVIEW Qbank/Customize Quiz - Manageme, *HURST REVIEW Qbank/Customize Quiz - Adult He, *HURST REVIEW Qbank/Customize Quiz - Basic Ca, *HURST REVIEW Qbank/Customize Quiz - Fundamen, ***HURST REVIEW NCLEX-RN Readiness Exam 1***, The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Edge Reading, Writing and Language: Level C, David W. Moore, Deborah Short, Michael W. Smith. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. a. A float nurse arrives on the unit to assist in the care of clients for the shift. Drag and Drop the items from one box to the other. Administering IV pain medication to a two day post op client. Include any relevant statements the client made about the ulcer b. a. Incorrect: This is not completely practical for everyone. This would be out of the UAP's scope of practice. 1. 1. The nurse is caring for four clients. c. The nurse may serve as a witness to informed consent for organ donation What proposal would the nurse determine to best meet the needs of families and clients in long term care? the nurse responds: "It must be very frustrating to encounter this kind of attitude." Monitor for GI upset 30 minutes after meals. The client must understand the need for restraints A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. Describe the types of machining operations that can be performed on a lathe. Encourage clients and families to develop mutually appropriate visitation times. 1. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". A home health nurse is conducting a home safety assessment for an older adult client. This is an elderly client who is a new admit. b. Irrigate the NG tube with 100 mL of sterile water The area surrounding the insertion site feels warm to the touch, 61. 4. d. Custard d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. 1. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? A nurse is caring for a client who has limited hand movement. Complete a client assignment sheet for the oncoming staff. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. 2. a. which client would be most appropriate to assign a licensed practical nurse (lpn)? Report the incident to the charge nurse c. Industry vs inferiority Assigning blame for the changes to administration will not help staff adjust. c. Tie linen bags securely at the top a. I'll urinate a little then stop Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. Evaluate pain relief after narcotic administration. Select all that apply a. 2. 3. c. I will inspect my crutches everyday for signs of wear b. I will try to anticipate and avoid stressful situations when possible Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. d. Transporting a cerebrospinal fluid specimen to the lab 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. What is the primary factor for the charge nurse to consider when delegating care? b. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. Both of these clients are terminal. c. Review the client's progress toward personal objectives Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Injuries from a motor-vehicle accident can be life threatening. 3. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. c. Use intermittent eye contact Which of the following pieces of PPE should the nurse remove first? Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. b. Urinary frequency for several days Which referral would most likely be appropriate for the nurse to make? Determining the client's length of stay Thus, the tasks involve successful management of the charge nurse's responsibilities. a. Auscultating heart sounds There is a possibility that a hypothermia blanket may be prescribed. A nurse is preparing medication for a client when another client has an emergency. In order to reorganize staffing, the nurse manager should initiate which action first? Monitor client for pain while assisting with ambulation. Which of the following tasks should the charge nurse reassign to a licensed nurse? a. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. The nursing supervisor may be able to assist with client care until another nurse can come in to work. Limit the client's fluid intake in the evening Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. Tenderness over the symphysis pubis A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). 1. There are a total of 10 adult clients. c. I suggest you talk with a mental health counselor about your concerns c. Interpersonal (interpersonal communication is face-to-face interaction with another person. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Temporary urinary retention (common for clients to develop after removal), 90. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. Use double bagging to remove soiled linen from the client's room Notify the primary healthcare provider of transfer completion. Which group of clients should she assign to the medical surgical nurse? 3. 1. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Document what the nurse believes was the cause of the ulcer development Which of the following responses should the nurse make? 4. However, there are some basic points which are standard among all facilities. This client could be transferred with traction still maintained. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 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. Client reporting epigastric pain and nausea after eating. Take several shallow breaths during the procedure 1. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. The supervisor can only send one LPN/LVN to the floor. Which of the following actions should the nurse take? What task would be best to assign to the LPN/LVN? 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. Client scheduled for breast reconstruction after mastectomy. d. Identifying the client by name when making a referral for home health services, 30. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? c. The client was restless and trying to get out of the bed all evening 2. Following a large hurricane, multiple clients arrive at the emergency room for treatment. c. 214 d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. e. Dysuria, 49. For which of the following tasks should the nurse wear protective eye equipment. a. The nurse has been assigned four clients. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? 3. The nurse should call for immediate help so that a safe care environment is maintained for all clients. Which of the following responses should the nurse make? What client should the nurse assess first? The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). In what order should the nurse see the clients? 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 needs careful monitoring and specialized care.