a. Pain Select all that apply Incorrect: There are situations in which the LPN must notify the primary healthcare provider. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. 1. 208 Assist a client to ambulate using a gait belt 1. Which of the following instructions should the nurse give to the client prior to the procedure? 3. b. c. Distended bladder Which of the following statements should the preceptor make? Incorrect: The nurse cannot assign teaching to the UAP. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. The abdominal pain is worsening. 2. d. 216, 22. Nursing questions and answers. 3. c. Explain the risks and benefits of the procedure 1. 4. d. I shouldn't advice you about what is ultimately a personal decision, b. A nurse has completed an informed consent form with a client. 2. e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. 1. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Cystogram reporting burning on urination. 5. c. Helping the client into the shower They are able to manage tasks related to basic care. 4. The last client would be the one needing dietary education. b. Irrigate the wound with an antiseptic prior to obtaining the specimen The client would develop severe cramping. 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. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. A lack of rapid eye movement (REM) sleep 3. 2. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. 2. A charge nurse is making assignments for an oncoming shift. The nurse is responsible for the assessment of all vital signs of post-op clients. Tenderness over the symphysis pubis Administer tap water enemas until clear at 6 AM. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. d. Counting radial pulse 2. 4. The nurse does not know the skills of the new UAP. An LPN/VN has been floated to the emergency room following a chemical plant explosion. Which of the following findings should the nurse identify as a safety risk? Phone report to the receiving nurse. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. 2. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. b. eminent Select all that apply d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. d. Do you think crying will help? b. 4. 5. a. Hanging a new bag of total parenteral nutrition (TPN). 3. When staff do not feel vested in any new process, there is a sense of underappreciation. Describe the types of machining operations that can be performed on a lathe. A nurse is caring for an older client who is at risk for skin breakdown. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. d. Identifying the client by name when making a referral for home health services, 30. Point out inconsistences in the client's behavior Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Elderly clients have special fluid and electrolyte issues after a fall. 4. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Which client would be appropriate for the RN to assign to the LPN? Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. The body needs vitamin B12 to make red blood cells. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. Decreased RBC production d. Place the tablet directly into a medication cup, 36. 3. a. Bathe a client who had an amputation 2 days ago d. I decline this opportunity at this time, b. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., 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). b. c. Can you tell me why you chose me? Which of the following indications should the nurse include? a. One nurse lifting as the client pushes with his feet c. Offer the client personal thoughts and beliefs A high concentration of carbon monoxide can cause death Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. Which of the following statements should the nurse make? Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. Which client can be assigned to the LPN? Incorrect: Informing is the same thing as teaching. Which of the following is the priority action by the nurse? b. b. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Select all that apply Incorrect: The RN is responsible for teaching. Assist a client to ambulate using a gait belt. b. Select all that apply. The nurse should not be assigned to provide care if impairment is suspected. 8. a. Increased insulin production A nurse is assessing a client who is experiencing prostatic hypertrophy. Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding). b. 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). Explain to the RN that all the nurses have the same number of clients. 4. 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. c. Open the right flap with the left hand a. 1) Bathe a client who had an amputation 2 days ago. What is the appropriate assignment? Explore the client's feelings 2. 4. Which of the following statements should the nurse identify as an indication that the client understands the instructions? Pick up the tray and tell the UAP that they didn't do a good job. Which of the following findings indicates that the client is meeting this goal? Which of the following actions is an example of a violation of confidentiality? Sudden attacks of sleep Monitor client for pain while assisting with ambulation. Which of the following infection-control precautions should the nurse use caring for this client? Incorrect: Atrial fibrillation places the client at risk for blood clots. b. Negligence Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? The client receives home health care and spends most of his day in a reclining chair. The nurse should use close-ended questions when assessing which of the following factors? b. Client diagnosed with inoperative brain tumor who is confused. 2. 5. This is an elderly client who is a new admit. b. The stem does not indicate any loss of neurological function resulting from the seizure activity. The option does not say the client is terminal, in a vegetative state, or in a coma. Anyone over age 18 can have an Advanced directive. Which of the following communication techniques should the nurse use during this phase? Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Which action by an unlicensed nursing assistant would require the nurse to intervene? d. Left forearm, b. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. 1. 3. The nurse received a client following surgery 8 hours ago. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Checking capillary refill beneath the client's fingernail Prior to shift report, the charge nurse is making assignments for the nurses on the shift. b. Discarding the first urine voided by the client starting a 24 hour urine test. d. When asking if the client took his medications this morning, 82. Remind the client to tell the nurse when he has to urinate c. Behaving defensively If the client is unstable, the nurse would retain the role of measuring the vital signs. which of the following actions should the nurse perform? a. 4. Accept assignment, documenting personal concerns regarding work conditions. Following the teaching, the nurse asks the client to describe one physical effect. Correct: The client who has a cast and requires pain medication is a stable and predictable client. 3. 2. Which of the following instructions should the nurse include? a. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. c. The client's culture (SATA) -Bathing a client who had an amputation 2 days ago. d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Measure urine output when client voids. 3. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. b. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 3. a. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 3. Incorrect: The RN is responsible for collecting data. Which of the following statements should the nurse identify as an indication the client needs further teaching? 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. Lisinopril 20.0 mg PO daily 3. They are likely to wait for others to initiate conversation Client diagnosed with Guillain-Barre' who is receiving ventilator support. This is a diabetic clinic. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. A. Encourage the client to use self-exploration c. Inflate the balloon when the urine flow stops The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. This service began with the client's admission to the hospital A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Removing the abdominal dressing Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. a. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Which of the following types of communication breakdown does this response represent? Client reporting a headache and has a fruity breath. In what order should the nurse see the clients? Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. 3. 3. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 4. This service began with the client's admission to the hospital, 18. 1. 4. b. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. c. Paraphrasing b. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Document what the nurse believes was the cause of the ulcer development Which clients should be assigned to the CNA? 4. 1., 2., & 5. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. The client is getting better. 1. d. Voided 30 mL frequently e. Talking with the client's partner, 79. Teach the UAP to change surgical dressings. 1. Which of the following info should the nurse include? Refuse the delegated intervention. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). a. What client should the nurse assess first? b. a. Which of the following instructions should the nurse include? b. I'm so sorry to hear about this 1. 1. Select all that apply. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Which of the following interventions should the nurse include? Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. c. Assist the client to the floor and begin mouth-to-mouth Injuries from a motor-vehicle accident can be life threatening. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 3. c. Request a tray without pork 1. 2. Incorrect: The client does need to have food; however, there is another action that should be performed first. 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. d. Decreased calcium excretion, c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown), 27. A float nurse arrives on the unit to assist in the care of clients for the shift. Which client should the nurse see first? Battery Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? A client with a fractured right humerus who reports the cast is too tight. The healthcare team should recognize the client as the center of the team. Relax her abdominal muscles when she lifts an object The client must understand the need for restraints 4. c. Washes and rinses her hands for 10 seconds This would be out of the UAP's scope of practice. d. Explain oral hygiene to a client receiving chemo As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. This is an appropriate prescription. A nurse is developing a plan of care for a client who practices Islam. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. b. Which of the following actions is the nurse's priority? Which of the following statements should the nurse make? 1., 4., & 5. b. Sit side-by-side with the client A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Focus on the client's present circumstances instead of his personal stories Speak using his usual tone of voice There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Client scheduled for breast reconstruction after mastectomy. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. b. We do not know the extent of her injuries based on what the option tells us. 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. Wrapping the dentures in tissue while the client sleeps Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. b. Assigning tasks to an AP This client is not the nurse's first priority. Showing disapproval The nurse suggest that the family might need to respite care services. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. This stage is when testing occurs to identify boundaries of interpersonal behaviors A nurse wants to find out a better way to perform oral care on unresponsive clients. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Client reporting epigastric pain and nausea after eating. 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. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. 3. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. The LPN/LVN can reinforce teaching. a. Bathtub with rails 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. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Performing passive range of motion (ROM) on the client with right sided paralysis. Incorrect: The nurse is responsible for monitoring a client. e. Feed a client who had a stroke 3 months ago, 32. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Change the subject when the client behaves defiantly (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. Which of the following should the nurse identify as an interpersonal variable? The nurse has just completed a 12 hour shift. b. c. They tend to use more verbal communication Decreased or suppressed respiration are priority. Which clients should be assigned to the CNA? Notify the surgeon that the client wishes to withdraw informed consent for the procedure Select all that apply. Select all that apply 1., 3, & 4. 2. It is not a routine task. Channel (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. 2. A client with COPD complaining of shortness of breath on exertion. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. Gather and apply dressings to open wounds. Which of the following explanations should the nurse provide? The cleint's family asks the nurse for info about this type of care. 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. Which of the following actions should the nurse take? A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). 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. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. (Select all that apply) Correct: The unlicensed nursing assistant should not turn tube feedings off or on. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. This would be out of the UAP's scope of practice. c. Hold an object away from her body as she lifts it A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. d. principal. This is normal for clients with hemorrhoids. 3. 4. 1, 3 & 5. 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 Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. c. I will place an area rug at the entry of my bathroom Based on these findings, to which of the following providers should the nurse request a referral for the client? d. Perception 1. Read all the current literature related to oral care on unresponsive clients. 2. 2. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. 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. Which nursing intervention should the charge nurse implement? Discuss the issue with the leader of the "best practices" committee. 2. d. Routine acquisition of a urine specimen In the following sentences, circle each incorrectly used lowercase letter. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? b. Urinary frequency for several days a. b. Massage any bony prominences to promote circulation 3. 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. d. Droplet, d. Bend at the knees when picking up an object, 98. A charge nurse is making client care assignments. Which of the following RNs should not be assigned to this baby? 2. Assist a client to ambulate using a gait belt This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. Protective 3. What was the hint? The nurse asks why the client needs to know this. Female client stating she has been raped. It's just not the right time for me to do this Remove all metal necklaces c. Palpating for pedal edema Discussing a client's surgical procedure with the nurse manager It would not be appropriate to overload this new employee with extra work. This is a task that can be delegated to the LPN/LVN. b. What information should the nurse include? Hold the penis at a 30 to 45 degree angle when inserting the catheter D. 4. The provider must renew a restraint prescription every 8 hr. c. Offering false reassurance Select all that apply. Nothing by mouth (NPO). 2) Assist a client to ambulate using a gait belt. Have another nurse guard the medication preparations until the nurse returns Charge nurses have integral roles in healthcare organizations. An experienced person who can research "best practice" regarding the issue is needed. Did you recognize ureterolithiasis as "kidney stones"? Who should the nurse see first? 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. The cause of the fall may be cardiac, but the question does not indicate this. The client asks about his medications and their effects. 2. c. Discard the tablet and obtain another dose of medication 3. d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. The nurse should perform which of the following activities in this space? Which of the following info should the nurse include? Place the client in a lateral position Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. a. Auscultating heart sounds Elderly client who fell and fractured the left femoral neck. the nurse responds, "don't worry, no one will harm your family." Transfer essential medical record to the receiving facility. 1. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Identify and assess each incoming client. 1. Incorrect: This group of clients needs specific teaching. Client with chronic emphysema experiencing mild shortness of breath. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. a. 1. a. 2. Which client should be assigned to the most experienced nurse? There may be a good reason that the tray was not served. Place in priority order. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. 3. This includes medication enemas. Which clients would be appropriate assignments for the LPN/LVN? A client with fibromyalgia reporting generalized pain of 7 out of 10. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. Which prescription should the nurse question and have corrected? Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? b. 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. The surgeon initially prescribes a clear liquid diet. 1. The nurse chooses to confront the client. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. The nurse should not lecture, scold or argue with the float nurse. Review a low-sodium diet for a client who has hypertension. 4. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound December 5, 2020. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. a. There is a trailing zero after the prescribed dose. In order to reorganize staffing, the nurse manager should initiate which action first? If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. 2. A nurse is caring for a client who states, "I have got to get out of this hospital! Nurses Report Sheet Template Nicu. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. Which of the following types of torts has the nurse committed? The nurse prefers to check all vital signs on all clients. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days.
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