the nurse responds: "It must be very frustrating to encounter this kind of attitude." This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. 4. Obtain a bedside commode for the client's use A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. which client would be most appropriate to assign a licensed practical nurse (lpn)? 2. For which of the following tasks should the nurse wear protective eye equipment. The nurse should call for immediate help so that a safe care environment is maintained for all clients. A client with fibromyalgia reporting generalized pain of 7 out of 10. c. Why are you crying? A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. A list of current medications is sent to the facility. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. c. Review a low-sodium diet for the client who has hypertension Incorrect: It is out of the UAP's scope of practice to administer medication. Nothing life threatening. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. a. Which actions should be instituted by each unit's charge nurse? A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. Incorrect. Which of the following actions should the nurse take? Charge nurses have integral roles in healthcare organizations. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. 1. (Select all that apply.) Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? a. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago Call the client's provider 4. Now, in Option #2, we see a dangerous prescription. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. b. Grape juice d. Explain oral hygiene to a client receiving chemo What is the most appropriate action by the charge nurse? c. Use an aggressive tone of voice Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Which client should the nurse assess first? Placing the traction weights on the bed to transfer the client to x-ray. Use double bagging to remove soiled linen from the client's room a. a. There are a total of 10 adult clients. 2. Which of the following instructions should the nurse include? a. 4. 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. Which of the following pieces of PPE should the nurse remove first? The area surrounding the insertion site feels warm to the touch A. Transporting a client who experienced a stroke 72 hr ago to the radiology department Provides safe, effective delivery of patient care in . This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. Return any fresh linen not used for a client to the linen supply area A client requesting assistance packing his belongings for discharge later today., Assist the float nurse with the clients case. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. }? benefactor of the world. c. Blood-tinged urine Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. Cystogram reporting burning on urination. b. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a 3. 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). Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. 2. Furosemide 40 mg PO q.d. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). December 5, 2020. Which of the following items should the nurse offer the client? The nurse caring for the client at the time of death requests organ donation Education A. a. Elicit info from the client A client receives a wrong medication. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. a. b. Which clients should be assigned to the CNA? 1., 2., 3., & 4. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. c. Tie linen bags securely at the top c. Open the right flap with the left hand The client can indicate desire for Do Not Resuscitate (DNR). Select all that apply The LPN should refuse the intervention. d. Water heater temp 54.4 C (130 F) To focus on effective learning with this client, which of the following interventions should the nurse use? 3. Assist a client to ambulate using a gait belt. Include any relevant statements the client made about the ulcer, 64. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Select all that apply A nurse is caring for a client who is postoperative following an appendectomy. This client needs ongoing monitoring which is within the scope of practice for the LPN. This client is stable and predictable. To remove gastric acid that might cause dyspepsia The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Select all that apply 3. d. Transporting a cerebrospinal fluid specimen to the lab To which of the following rooms should the nurse assign the client? d. I will place a bath seat in my shower to use when I bathe, b. The charge nurse knows what client would be most appropriate for this LPN? Normally, red blood cells are flexible and round, moving easily through blood vessels. Client with ureterolithiasis who requires frequent PRN pain medication. Discussing a client's surgical procedure with the nurse manager 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. Which of the following actions should the nurse include in the plan? 4. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. 2. (Select all that apply.). c. Industry vs inferiority Triage and assign color-coded tags to each client. Speak to the UAP to determine what happened with the feeding. 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. Correct: The UAP can remind the client to do something that has already been taught by the nurse. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. d. Determine if the client uses hearing aids, b. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? A nurse is caring for a client who is postoperative. 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. Plan all care to be completed in early morning to allow afternoon for visitation. Client one day post kidney transplant. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. 3. 4. b. Irrigate the NG tube with 100 mL of sterile water (Select all that apply.). c. Behaving defensively Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Which of the following actions should the nurse perform when opening the sterile pack? In the following sentences, circle each incorrectly used lowercase letter. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. The women's health charge nurse is making assignments for the next shift. 5. The nurse cannot allow the UAP to perform advanced tasks. A nurse is teaching a client about the physical effects of chemotherapy. 2. Thoracentesis reporting shortness of breath. a. A charge nurse is making assignments for an oncoming shift. These individuals are selected by the charge nurse, and do not have to be nurses. Protective Place in priority order. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. When a family member asks how respite care can help, which of the following responses should the nurse provide? Moistening the dentures prior to inserting them b. I will come back later and we can talk d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. c. Include intact skin at the wound edges in the culture There are a total of 10 adult clients. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? Remind the client to avoid tight fitting clothes. The other options may be correct but are not the best first action. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? b. The cause of the fall may be cardiac, but the question does not indicate this. 2. 3. Which of the following actions should the nurse take first? A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. "Please explain what you mean by the word 'nervous'.". d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound Client with cast to right leg requiring pain medication. d. Reduced blood viscosity, a. Auscultating heart sounds Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. The charge nurse should notify the nursing supervisor who will seek additional staff. Compartment syndrome could be developing which can impede circulation and cause nerve damage. Focus on the client's present circumstances instead of his personal stories Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. c. The restraints should promote the client's safety and prevent injuries c. Explore the client's feelings about dietary modifications In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. This service focuses on teaching the primary caregiver to meet the client's needs Handoff and Nursing Report Sheet. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Which of the following statements should the preceptor make? 1. A client with an above the knee amputation reporting phantom pain. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. b. Wash the tablet off with alcohol and place it in a clean medicine cup Which of the following of Erikson's developmental stages should the nurse consider in the planning? c. Consensus evolves in this stage c. imaginary c. Review the client's progress toward personal objectives Which of the following actions is an example of a violation of confidentiality? 1. Which of the following actions should this nurse take? 4. a. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. 3. During exacerbation, the client will have many diarrhea stools. 1. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. - Assisting a client to ambulate using a gait belt. 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. Incorrect: This group of clients needs specialized care. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. Well, do you see the q.d.? A nurse is teaching a client who has a history of falls about home safety. Ambulating a client who is 2 days post vaginal hysterectomy d. Let's wait until tonight to see if he continues his behavior, 63. The nurse is focusing on which of the following elements of the communication process? 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. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Which of the following RNs should not be assigned to this baby? a. 2. a. 1. Which clients should be assigned to the CNA? Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Select all that apply. a. Did you recognize ureterolithiasis as "kidney stones"? Select all that apply Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. 3. Which of the following infection-control precautions should the nurse use caring for this client? Which of the following info should the nurse include? b. d. Remove tea and coffee from meal trays, b. *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. Explain oral hygiene to a client receiving chemotherapy Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. Encourage the client to use self-exploration Soaking the dentures in hot water 3. Incorrect: Informing is the same thing as teaching. Refuse the assignment, being prepared for disciplinary action. The client post PEG placement is stable. Ask the primary healthcare provider to suggest the best oral care procedure. 2. The RN with 5 years' experience in the Labor and Delivery unit. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. Which of the following findings should the nurse expect? 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. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. c. Hallucinations at the onset of sleep, 65. Client reporting epigastric pain and nausea after eating. The nurse has been assigned four clients. a. 3. c. Washes and rinses her hands for 10 seconds 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. 5. b. I will try to anticipate and avoid stressful situations when possible c. I will complete the smoking cessation program I started c. The client was restless and trying to get out of the bed all evening The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? 3. 4. Collecting I & O totals for unit clients at the end of shift. Which of the following statements by the student indicates understanding of the discussion? In what order should the nurse see the clients? Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Hanging a new bag of total parenteral nutrition (TPN). Assist client to brush and floss teeth. What action should the nurse take after mistakenly administering the wrong medication? Airborne Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 2. Place in priority order. _________________ (magnanimous), a. generous Incorrect: Moistening the dentures will ease insertion. The client says, "go away, no one can help me." No! This stage is when testing occurs to identify boundaries of interpersonal behaviors A medical-surgical LPN has been sent to a short-staffed pediatric unit. Right forearm 3. b. I'm so sorry to hear about this Which client would be appropriate for the RN to assign to the LPN? Monitor for GI upset 30 minutes after meals. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. Nothing will get passed the complete blockage. The RN with 8 years' experience in the Intensive Care Unit. b. c. I will make sure my visitors smoke outside 2. 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. b. 77. 1., 4., & 5. Denial 2. Convenience for the nursing staff or the client's family Incorrect: The nurse cannot assign teaching to the UAP. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. 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. 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. Ask for any staff objections to rearranging work hours. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. A nurse is providing care to a client who is on strict bed rest following surgery. Gather and apply dressings to open wounds. What would the approximate meaning of photoelectric be, based on these root words? c. I will place an area rug at the entry of my bathroom a. Incorrect: No, the monitoring is too specific for the med-surg nurse. However, providing care for missing teeth would also be within the LPN scope of practice. What proposal would the nurse determine to best meet the needs of families and clients in long term care? What was the hint? The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS).
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