Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. c. Review another client's similar surgical experience Tenderness over the symphysis pubis A client requesting assistance packing his belongings for discharge later today., Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. Left upper forearm A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. Monitor for GI upset 30 minutes after meals. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. Only the state Board of Nursing can legally determine the LPN's scope of practice. The facility has insurance that will cover malpractice litigation A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. the nurse responds, "don't worry, no one will harm your family." The nurse should assess the client for which of the following expected outcomes after catheter removal? Teaching insulin self administration cannot be delegated to the LPN. Allow families unlimited visitation around the clock to meet their schedules. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. The client can indicate desire for Do Not Resuscitate (DNR). Determine which personnel could be sent to the command center. Which client should the nurse assess first? Perform range of motion (ROM) exercises at least 2-3 times daily Placing a washcloth in the bathroom sink prior to cleaning. Obtain a urine specimen from a client with an indwelling Foley catheter. c. imaginary This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. Although this will require assessment, this client is not the priority at this time. The nurse is using which level of communication at this time? Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. For which of the following actions should the nurse intervene? A charge nurse is making client care assignments. 4. Risperidone .5 mg PO daily c. Interpersonal (interpersonal communication is face-to-face interaction with another person. This client will also need a lot of education regarding anti-rejection medications. 1. d. Sleep apnea a. 4. Report of feeling pressure 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. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. 4. b. Wash the tablet off with alcohol and place it in a clean medicine cup 3. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. b. A nurse is prioritizing care for two clients at the start of the shift. 1. Feed a client that had a stroke 3 months ago. The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. 3. This client can wait until the others are treated. c. One nurse lifting the client's legs as the client uses a trapeze bar b. b. Verbalize understanding of how the client feels As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Which of the following instructions should the nurse include? A nurse who is breastfeeding her 4 month old. 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. (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. Which group of clients should she assign to the medical surgical nurse? When determining if the client is eating a well-balanced diet Accept the client's behavior as confrontational. 2. A nurse is engaging in relationship counseling with a male client. Incorrect: This is not completely practical for everyone. The nurse suggest that the family might need to respite care services. b. The nurse has another priority. Now, in Option #2, we see a dangerous prescription. a. Based on this information,what should the nurse do? d. Message, 67. Changing a colostomy bag. In option #4, we see that the leading zero is missing from the prescription. 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. 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. d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. 1., 4., & 5. Alcoholic Anonymous Include any relevant statements the client made about the ulcer c. Do not eat or drink anything the morning of the test Incorrect: The RN is responsible for assessment and evaluation of clients. - Assisting a client to ambulate using a gait belt. 2. Answer the following question to test your understanding of the preceding section: d. Move to the opposite side of the pack and open the fourth flap, 54. Phone report to the receiving nurse. Drag and Drop the items from one box to the other. 5. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. a. Female client stating she has been raped. c. I should purchase a carbon monoxide detector for my home 3. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter a. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? The client states, "I'm feeling a bit nervous today." b. c. Respite care helps relieve pain and promote comfort 3. 1. There are a total of 10 adult clients. a. d. Motor impairment, 84. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. Correct: The client has the right to be involved in the decision making of their care. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Licenced practical nurses are a little less educated than registered nurses. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. The expected standard of care was strict bed rest), 96. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. In what order should the emergency department triage nurse send these clients to a room for treatment? This client needs ongoing monitoring which is within the scope of practice for the LPN. Which of the following infection-control precautions should the nurse use caring for this client? The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. Notify the surgeon that the client wishes to withdraw informed consent for the procedure a. The nurse voices his concern to the charge nurse. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Correct: The medical nurse can be assigned to this client. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. a. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? d. Do you think crying will help? Which of the following instructions should the nurse include? In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. Complete a client assignment sheet for the oncoming staff. 2. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. c. When asking the client how he completes his ADLs The nurse caring for the client at the time of death requests organ donation What client should the nurse assess first? Elderly client admitted 30 minutes ago with reports of constipation for four days. In which harmonic number n is the string vibrating? A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. b. Education A charge nurse is observing a group of newly licensed nurses. b. Numbness This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. c. Use intermittent eye contact Assist a client to ambulate using a gait belt. Estimate the number of Calories in two tablespoons of peanut Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. b. Assigning tasks to an AP Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. c. Foot Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. 3. In order to reorganize staffing, the nurse manager should initiate which action first? Incorrect: It is out of the UAP's scope of practice to administer medication. The area surrounding the insertion site feels warm to the touch Correct: Traction should never be relieved without a primary healthcare provider's prescription. Explore the client's feelings A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Take several shallow breaths during the procedure 2. What was the rationale for this plan? 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. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. 2. Start MgSO4 at 3g/hr IV Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. c. Review a low-sodium diet for the client who has hypertension d. Perception Prior to turning feeding back on, tube placement needs to be verified. There is a trailing zero after the prescribed dose. A cardiac step down unit has requested float staff because of multiple impending admissions. A nurse is teaching a client about the physical effects of chemotherapy. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. c. Paraphrasing a charge nurse is making client care assignments for the day. 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). d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. December 5, 2020. e. The urge to move the legs when trying to sleep, 66. d. Droplet, d. Bend at the knees when picking up an object, 98. Assist the float nurse with the clients case. 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. Incorrect: This would unnecessarily alarm the clients. 5. Nothing life threatening, but an assessment needs to be made regarding the ulcer. Place the client in a lateral position c. Holds the soiled linen against her body while carrying it to the linen bag A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. There are a total of 10 adult clients. 2. the nurse should delegate collection of which of the following specimens to DismissTry Ask an Expert Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Harvard University University of Georgia Maryville University 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. c. Hallucinations at the onset of sleep, 65. 3. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Client who is a diabetic experiencing diabetic neuropathy. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. c. Why are you crying? Richied5864 Richied5864 . 1. (Select all that apply.) Feedback Reach around the pack and open the top flap away from the body Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. a.) Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 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. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. This client needs careful monitoring and specialized care. A nurse is caring for a client who has limited hand movement. When staff do not feel vested in any new process, there is a sense of underappreciation. b. Ask the primary healthcare provider to suggest the best oral care procedure. Select all that apply. 1. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). a. 2. d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. A client post pacemaker insertion, awaiting discharge instructions. Which of the following actions should the nurse take to assist the client with feeding? 1. a. Obtain a client's consent This individual should be provided appropriate comments of appreciation for this accomplishment. Select all that apply. A charge nurse is making client care assignments. 4. 3. a. 2. c. Notifying the provider of physical exam findings Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Rewrite each incorrect sentence to correct the error. c. Palpating for pedal edema A client on a surgical unit frequently quarrels with the staff. c. Can you tell me why you chose me? Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. Provide a between meal supplement to the client. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Which of the following tasks should the nurse delegate to AP? Discuss the assignment with another LPN. d. Lean back in the chair, b. d. They disclose more personal information, a. Speak to the UAP first and then decide if a between meal supplement is needed. Write N next to the nonessential clauses and E next to the essential clauses. Which clients should be assigned to the CNA? Explain oral hygiene to a client receiving chemotherapy These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Which of the following approaches should the nurse use when using confrontation? Decreased or suppressed respiration are priority. 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). 4. This client is stable and predictable. The nursing supervisor may be able to assist with client care until another nurse can come in to work. 2. 1. The client is considered unstable until assessed by the nurse. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Nothing will get passed the complete blockage. 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. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. Review a low-sodium diet for a client who has hypertension. What action should the nurse implement first to ensure client safety? Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? 2. Provide positive feedback to the UAP. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Obtain a bedside commode for the client's use A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. A school-aged child with a fractured femur who is in balanced suspension traction. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. 4. Triage and assign color-coded tags to each client. 212 Which of the following activities should the nurse perform in this zone? 6. 3. Which of the following communication techniques should the nurse use during this phase?
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