Assist ait to ambulate using a gait belt. Which of the following instructions should the nurse include? Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. c. Provide the client with a diet high in protein A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. What is the best response by the charge nurse? Select all that apply. 4. -Review a low-sodium diet for a client who has HTN The charge nurse is planning the staff assignments for the clients on a neurological unit. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? 3. b. I will come back later and we can talk Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. 212 2. c. Paraphrasing A post-cardiac catheterization needing assistance with bedpan. Simply accept the assignment since overtime is mandatory. c. Consensus evolves in this stage Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Focusing Send a day's worth of medications with the client to the receiving facility. Assist the float nurse with the clients case. c. I suggest you talk with a mental health counselor about your concerns c. Washes and rinses her hands for 10 seconds, 11. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. A nurse is caring for a client who is about to have a colonoscopy. A person can be designated to make medical decision in the event the client cannot. If a sentence is already correct, write CCC. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Which of the following items should the nurse offer the client? Which of the following statements by the student indicates understanding of the discussion? Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 4. 1. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). c. Can you tell me why you chose me? Provide an adaptive feeding device for the client, 50. 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. c. Environment Client scheduled for a dressing change to foot ulcer. b. Evaluate client's safety risk factors. b. Determine caregiver's stress level and coping strategies. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. 2. 3. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. This stage involves constructive efforts on the part of the group members This is a diabetic clinic. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Select all that apply 2. c. Request a tray without pork 5. Lumbar puncture reporting a headache. Which of the following instructions should the nurse give to the client prior to the procedure? 4. A nurse is caring for a client who expresses anxiety about his impending surgery. d. I decline this opportunity at this time, b. Providing hygiene care to a client who is HIV positive The stem does not indicate any loss of neurological function resulting from the seizure activity. 5. December 5, 2020. 2. 3. A nurse is caring for a client who is postoperative following an appendectomy. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. 3. Which of the following findings should the nurse expect? 1., 2., 4., & 5. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). A nurse is planning to discharge a client who has quadriplegia to his home. 1. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. This client needs careful monitoring and specialized care. Yes! Thus, the tasks involve successful management of the charge nurse's responsibilities. Offer to take one of the clients. Following a large hurricane, multiple clients arrive at the emergency room for treatment. 8. 3. Client who has multiple injuries from a motor vehicle accident. 1. Initiate oxygen and IV lines as needed. a. 4. Relief of urinary retention Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. Select all that apply. A client with an above the knee amputation reporting phantom pain. 4. The RN with 2 weeks' experience on the postpartum unit. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? The nurse should assess the client for which of the following expected outcomes after catheter removal? Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. "The client is weak on the right side, so please assist the client with dressing . b. 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? A nurse is orienting a new assistive personal (AP) to the unit. This service began with the client's admission to the hospital A charge nurse is making client care assignments. This would be out of the UAP's scope of practice. c. Contact Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. . Incorrect: The charge nurse does not have to assess every client. 4. The LPN/LVN can reinforce teaching. Which of the following statements should the nurse make? Try different methods of oral care on unresponsive clients to see what works best. c. Take the client to the bathroom every 2 hr b. 1. Where on the body is each type of skin found? 2. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. a. They are likely to wait for others to initiate conversation 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. The nurse received a client following surgery 8 hours ago. b. 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. Reach around the pack and open the top flap away from the body e. Feed a client who had a stroke 3 months ago, 31. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Select all that apply. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 4. Correct: Hot water may damage dentures so intervention is needed. c. Review the client's progress toward personal objectives Decide which choice fits best in the blank. A nurse is caring for a client who is immobile. Incorrect: The nurse cannot assign teaching to the UAP. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. b. Refuse the overtime assignment, being prepared for disciplinary action. Decreased or suppressed respiration are priority. 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? 3. Which clients could be assigned to an LPN? 1. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. Use double bagging to remove soiled linen from the client's room The nurse should do this when repositioning is needed. The client was lying on the floor next to his bed a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. Have another nurse finish preparing the medications b. Negligence d. They disclose more personal information, a. An experienced person who can research "best practice" regarding the issue is needed. This determination is needed to assure client safety is being considered. Notify the charge nurse of the observations. Which of the following instructions should the nurse include? Incorrect: This prescription is written correctly. Which clients should be assigned to the CNA? When assigning nurses to patients, the charge nurse must consider the acuity of the patient's condition, the skills of the nurse, and the availability of other staff members. 5. c. The client was restless and trying to get out of the bed all evening Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Provide a between meal supplement to the client. 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. Which of the following indications should the nurse include? Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. Cystogram reporting burning on urination. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. Provides day to day direction and supervision to assigned direct patient care staff. Warm the feeding solution to the body temperature Autonomy vs shame and doubt These individuals are selected by the charge nurse, and do not have to be nurses. 6. A client requesting assistance packing his belongings for discharge later today., d. I will place a bath seat in my shower to use when I bathe, b. 3. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. b. 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. c. Leave a nightlight on in the client's room Only the state Board of Nursing can legally determine the LPN's scope of practice. There may be a good reason that the tray was not served. c. Gender Correct: This group of clients is primarily med surgical. This is not a situation that requires the LPN to notify the primary healthcare provider. Client with a T-5 spinal cord injury beginning rehabilitation therapy. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Which of the following nontherapeutic communication techniques is the nurse using? b. The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). 4. The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. c. I will make sure my visitors smoke outside 4. a. I will wear gloves when removing food from the freezer 1. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Patient safety must remain the priority. 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. Which region of the tRNA pairs with mRNA? Changing a colostomy bag. In which situation should the nurse consult the client's advanced directive? a. d. Establishing the client's secondary medical diagnoses, b. Sudden attacks of sleep 1. Notify the nursing supervisor of the situation. Donning gloves and using a gauze pad to grasp and remove dentures The nurse should perform which of the following activities in this space? Provide positive feedback to the UAP. Ask the client to perform a return demonstration of insulin injection Changing the subject The charge nurse's best response is to first obtain the needed information to make the best decision. b. Nothing life threatening, but an assessment needs to be made regarding the ulcer. 4. Point out inconsistences in the client's behavior a. a. a. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. 4., & 5. Ask the charge nurse to evaluate the intervention. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. & 6. a. Which client should the nurse see first? Empty the drainage bag at least every 8 hrb.) a. I wish I didn't have to attach the electrodes to my skin b. Remove all metal necklaces Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. c. Blood-tinged urine c. Complete an incident report American Sickle Cell Anemia Association 1. 2. Respite care allows the primary caregiver time away from day-to-day care responsibilities The healthcare team should recognize the client as the center of the team. a. (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. c. The client's culture a. 3. Discussing a client's surgical procedure with the nurse manager a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter Remind the client to tell the nurse when he has to urinate Of my three brothers and sisters, my sister Giselle has the best sense of humor. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. b. Request a prescription for a medication to ease the client's anxiety Start MgSO4 at 3g/hr IV Check environment for potential safety hazards. d. Assault, b. a. I will begin 48 hr before the client's discharge 2. 1. 6. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Use the tablet's packaging to pick it up from the counter Call the client's provider a. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. b. Assigning tasks to an AP Which of the following responses should the nurse provide? Which task should the nurse take responsibility for completing? Furosemide 40 mg PO q.d. The surgeon initially prescribes a clear liquid diet. Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. 2. Document current functional status assessment Ask the primary healthcare provider to suggest the best oral care procedure. Most of the following sentences contain errors in the use of modifiers and comparisons. Place in priority order. Cardiac catheterization with a decreased pedal pulse below insertion site. Select all that apply Disconnect client's nasogastric (NG) tube suction to allow ambulation. Have another nurse guard the medication preparations until the nurse returns 3. a. Inform the client of the need to avoid irritants such as carbonated beverages. one of the licensed practical nurses Get the answers you need, now! Each ROM movement should be repeated 5 times during the session. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. The women's health charge nurse is making assignments for the next shift. Feed the client after warming the food. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Correct: The client who has a cast and requires pain medication is a stable and predictable client. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Which of the following actions should the nurse take? Correct: The medical nurse can be assigned to this client. The charge nurse needs additional information to make a decision. c. Decreased sodium excretion He charge nurse is making client care assignments for the evening shift. 1. What task would be best to assign to the LPN/LVN? A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. 2. d. Custard c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). If the client is unstable, the nurse would retain the role of measuring the vital signs. 4. 1. The nurse has another priority. d. Move to the opposite side of the pack and open the fourth flap, 54. Which of the following is the priority action by the nurse? This task cannot be delegated to the LPN/LVN. 3. A nurse who is breastfeeding her 4 month old. 3. Notify clients that the disaster plan has been put into effect. b. I will bear the weight of my body on my hands d. principal. b. This is normal for clients with hemorrhoids. d. Identifying the client by name when making a referral for home health services, 30. 3. d. Respite care is a continuation of psychological support after a family member dies. c. Foot Select all that apply c. Initiate a liquid diet for the client If you give the magnesium citrate, which is a laxative, what will happen? c. Inflate the balloon when the urine flow stops A nurse is assessing a client at a follow-up clinic for acute low back pain. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). A client receives a wrong medication. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 4. Thoracentesis reporting shortness of breath. d. Lean back in the chair, b. 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. 3. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. The reason for the UAP not feeding the client needs to be determined. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Ambulating a client who is 2 days post vaginal hysterectomy What is the best care assignment for this client? 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. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. e. Feed a client who had a stroke 3 months ago, 32. 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. d. I shouldn't advice you about what is ultimately a personal decision, b. To remove gastric acid that might cause dyspepsia The infusion rate has stopped but the tubing is not kinked Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Tenderness over the symphysis pubis 2. 2. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. c. They tend to use more verbal communication Elderly client admitted 30 minutes ago with reports of constipation for four days. 1. a. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. }? benefactor of the world. Teaching insulin self administration cannot be delegated to the LPN. a. Auscultating heart sounds They are able to manage tasks related to basic care. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 2. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. Besides yourself, there are the following staff: Your unit has 12 beds. Incorrect: The RN is responsible for assessment and evaluation. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. 1. Which of the following actions indicates that the AP understands the principles of infection control? A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. 1. Which client should the nurse assess first? (Select all that apply) c. Discard the tablet and obtain another dose of medication This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). A. b. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. 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." d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. 2. 4. 5. Which of the following actions by the nurse is considered an indirect nursing care activity? Which of the following responses should the nurse make? 2. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage A medical-surgical LPN has been sent to a short-staffed pediatric unit. The nurse caring for the client at the time of death requests organ donation Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Placing the traction weights on the bed to transfer the client to x-ray. 4. Prior to turning feeding back on, tube placement needs to be verified. a. Correct: Traction should never be relieved without a primary healthcare provider's prescription. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. a. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. d. When asking if the client took his medications this morning, 82. 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. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Select all that apply. Witness the client's signature A nurse enters an older adult client's room to insert a saline lock. Invite staff to contribute ideas on scheduling changes. 4. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. 1. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. 1. 2. However, it remains true pain for this client and the client would need intervention to help manage this pain. b. eminent Incorrect: No, the monitoring is too specific for the med-surg nurse. c. Hallucinations at the onset of sleep 2. One important aspect is encouraging the flow of ideas between management and staff members. 2. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. This situation is considered an external disaster which means the hospital will be expecting multiple victims. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. b. I should call my doctor if I find it harder to concentrate What is the most appropriate action by the charge nurse? 6. The nurse who made the medication error should take which of the following actions first? Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. 1. Call the family of a client suffering from dementia to discuss long term care placement. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Which of the following responses should the nurse make? In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. b. 1. The provider must renew a restraint prescription every 8 hr. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. c. Assist the client to the floor and begin mouth-to-mouth Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. c. 214 Which of the following tasks should the nurse delegate to assistive personnel (AP)? The report should contain consequences. Wears a gown when entering the room of a client who requires contact precautions 4. Correct: Communication is important in delegation, as is follow-up. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?
a charge nurse is making client care assignments
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