Explain oral hygiene to a client receiving chemotherapy c. I will cover the catheter so he cannot see it Initiate oxygen and IV lines as needed. We do not know the extent of her injuries based on what the option tells us. d. Move to the opposite side of the pack and open the fourth flap, 54. Which region of the tRNA pairs with mRNA? An experienced person who can research "best practice" regarding the issue is needed. b. In the following sentences, circle each incorrectly used lowercase letter. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 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. An adolescent client post appendectomy reporting pain. & 5. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 4. b. A nurse is prioritizing care for two clients at the start of the shift. Did you think dehydration and fluid volume deficit? This is normal for clients with hemorrhoids. A client receiving a blood transfusion that requires monitoring. 3. 3. b. I will try to anticipate and avoid stressful situations when possible A nurse is discussing the norming stage of the group development process with a student nurse. "The client is weak on the right side, so please assist the client with dressing . Monitor for behavioral changes. The situation should be explored before bringing the supervisor in on the situation. a. 1., 2., 3., & 4. The nurse could definitely be part of the committee. 2. c. Behaving defensively Comatose client with end stage chronic obstructive pulmonary disease. Dentures should be stored in a denture cup. 4. c. Visual observation for nonverbal signs of pain 3. 8. The last client would be the one needing dietary education. What action should the nurse implement first to ensure client safety? Temporary urinary retention (common for clients to develop after removal), 90. Once the client is stable, the UAP could perform this task. Obtain a bedside commode for the client's use Which of the following actions is an example of a violation of confidentiality? c. Measurement of residual urine after urination 5. Administering IV pain medication to a two day post op client. c. Assist the client to the floor and begin mouth-to-mouth c. Shivering 4. 5. A client with diabetes admitted for debridement of a foot ulcer. Provide an adaptive feeding device for the client, 50. The charge nurse knows what client would be most appropriate for this LPN? A client requesting assistance packing his belongings for discharge later today.. 1 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. 2. Select all that apply. A client with exacerbation of COPD reporting dyspnea. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. Channel d. Water heater temp 54.4 C (130 F) This task cannot be delegated to the LPN/LVN. 5. Which of the following methods should the nurse plan to use? There is a trailing zero after the prescribed dose. is a new graduate in orientation. This referral would be appropriate. Lisinopril 20.0 mg PO daily There are a total of 10 adult clients. Which of the following instructions should the nurse include? Select all that apply 4., & 5. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. b. Emptying a urinary drainage bag for a client who has pneumonia A nurse is caring for a client who has a wound infection. 4. Place the client in a lateral position The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. Which of the following actions should the nurse take? This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. Teach the UAP to change surgical dressings. 4. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. Select all that apply. Select all that apply. 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). This is an elderly client who is a new admit. Relax her abdominal muscles when she lifts an object b. Which of the following actions should the nurse take? Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. b. Irrigate the NG tube with 100 mL of sterile water 1. The key word in the stem is first. Encourage the client to use self-exploration The provider must renew a restraint prescription every 8 hr. b. Urinary frequency for several days 2. A client with epilepsy reporting an odd smell in the room. a. Remind the client to avoid tight fitting clothes. Read all the current literature related to oral care on unresponsive clients. b. 3. 4. Incorrect: This again is assessment which is the role of the RN only. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Return any fresh linen not used for a client to the linen supply area Client to receive dietary education. In what order should the nurse see the clients? The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Incorrect: Atrial fibrillation places the client at risk for blood clots. Which of the following sites should the nurse plan to use to obtain the blood specimen? b. a. The nurse has received the change-of-shift report. 1. b. Which of the following statements should the nurse make? Obtain a client's consent Which of the following statements should the nurse identify as an indication that the client requires further clarification? 2. 4. Which of the following of Erikson's developmental stages should the nurse consider in the planning? A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Which of the following approaches should the nurse use when using confrontation? b. Negligence Decreased RBC production d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. c. Irrigating a client's abdominal wound 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. These are appropriate tasks for an UAP to complete. Respite care provides holistic support and care for a client who is terminally ill This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. c. Provide the client with a diet high in protein Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. Therefore, this client would not be a priority over a client who may be experiencing a MI. Administer sodium polystyrene sulfonate enema. a. Auscultating heart sounds Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. b. A client has been admitted with folic acid deficiency anemia. The LPN can monitor the wound and provide care to the PEG insertion site. 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 Correct: Hot water may damage dentures so intervention is needed. Only a plain enema or soap enema can be given by the UAP. Which of the following actions should the nurse take to assist the client with feeding? Temporary urinary retention 3. Evaluate client's safety risk factors. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Explain administration is demanding a decreased overtime. Irrigate a client's ear canal. What is the primary factor for the charge nurse to consider when delegating care? a. Gloves To which of the following rooms should the nurse assign the client? An LPN/VN has been floated to the emergency room following a chemical plant explosion. 3. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following activities should the nurse perform in this zone? Notify the nursing supervisor of the situation. 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. Thoracentesis reporting shortness of breath. 1. A goal for this client is to use proper body mechanics at all times. Everyone knows there are others who can chair this committee better than me d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 4. 3. A nurse is providing discharge teaching for a client who requires home oxygen therapy. This service began with the client's admission to the hospital a. I wish I didn't have to attach the electrodes to my skin Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? 1. a. Denial What is the best first action for the nurse to take in order to achieve this goal? Where on the body is each type of skin found? b. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures (Select all that apply.) Well, do you see the q.d.? b. Besides, a charge nurse is a leader on the floor and should possess . This is likely cholelithiasis, which will need to be checked out. The nurse is planning care for a client admitted with Alzheimer's Disease. 3. a. The nurse received a client following surgery 8 hours ago. d. Message, 67. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. 2. These individuals are selected by the charge nurse, and do not have to be nurses. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Which of the following tasks should the nurse delegate to assistive personnel (AP)? b. d. Discussing intake and output Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Correct: The client has the right to be involved in the decision making of their care. which of the following actions should the nurse perform? Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Measure urine output when client voids. a.) c. I should purchase a carbon monoxide detector for my home c. Contact 4. e. Throw rugs, 40. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. 3. Nothing will get passed the complete blockage. Which of the following explanations should the nurse provide? The RN with 2 weeks' experience on the postpartum unit. Which client should the nurse assess first? 5. Which of the following instructions should the nurse include? What is the best response by the charge nurse? 6. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 55. Client with a T-5 spinal cord injury beginning rehabilitation therapy. This would be an acceptable task to assign to the UAP. Review the action of insulin therapy Which of the following types of torts has the nurse committed? However, there are some basic points which are standard among all facilities. Document what the nurse believes was the cause of the ulcer development Identify and assess each incoming client. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Provide an adaptive feeding device for the client A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. The charge nurse should notify the nursing supervisor who will seek additional staff. A charge nurse is making client care assignments. d. 216, 22. 4. a. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse has another priority. d. Lean back in the chair, b. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Send a day's worth of medications with the client to the receiving facility. Incorrect: This would unnecessarily alarm the clients. Serve milk products separately from meals b. Summarization a. d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). c. Distended bladder Places the soiled linen in the floor before bagging it The client receives home health care and spends most of his day in a reclining chair. 3. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Which of the following should the nurse include as a criterion for applying restraints? 4. A nurse wants to find out a better way to perform oral care on unresponsive clients. Select all that apply. d. Highly concentrated urine, 91. 2. b. I'll do exercises that strengthen my abdominal muscles d. Place the tablet directly into a medication cup, 36. b. A client on a surgical unit frequently quarrels with the staff. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). This is an appropriate and safe action for the unlicensed nursing assistant to do. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? 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. 1., 4., & 5. Based on this information,what should the nurse do? Moistening the dentures prior to inserting them b. I should call my doctor if I find it harder to concentrate 1. Female client stating she has been raped. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. d. Explain oral hygiene to a client receiving chemo They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department 2. Simply accept the assignment since overtime is mandatory. 1., 2., 4., & 5. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Which of the following items should the nurse offer the client? 2. 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. For which of the following tasks should the nurse wear protective eye equipment. d. Voided 30 mL frequently Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. b. I will begin once the client's discharge order is written Dr. Frankenstein had seen himself as a(n) ?\underline{? 6. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. a. a. Incorrect: The RN is responsible for teaching. a. Shakes the soiled linen to remove any toilet paper remnants A school-aged child with a fractured femur who is in balanced suspension traction. 2. (SATA) -Bathing a client who had an amputation 2 days ago. 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. 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. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound A nurse is filling out an incident report after finding a client lying on the floor. c. Confrontation Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? In order to reorganize staffing, the nurse manager should initiate which action first? CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. Electric cords behind the furnitrure Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. He charge nurse is making client care assignments for the evening shift. d. Social conversation, a. The client then states, "I have changed my mind and do not want to have the procedure done." A. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. The nurse should call for immediate help so that a safe care environment is maintained for all clients. b. 1. a. 2. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Which client should the nurse see first? This would be out of the UAP's scope of practice. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Focusing The charge nurse needs additional information to make a decision. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Gathering needed equipment and supplies is within the scope of duties for the UAP. Placing the traction weights on the bed to transfer the client to x-ray. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter c. Providing anticipatory guidance to a client in crisis 3. Talk to each nurse about concerns related to assigned clients. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. Accept the client's behavior as confrontational. a. d. Counting radial pulse Currently, your census is 11, with one empty bed. 3. Which group of clients should she assign to the medical surgical nurse? Phone report to the receiving nurse. The nurse should assess the client for which of the following expected outcomes after catheter removal? Photo comes from the Greek word for light. b. a. A nurse is providing care to a client who is on strict bed rest following surgery. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. c. Raised toilet seats Make nursing assignments appropriate to the skill level . A client post pacemaker insertion, awaiting discharge instructions. 5. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. Injuries from a motor-vehicle accident can be life threatening. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. The charge nurse on the postpartum unit is making assignments. Select all that apply. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. The nurse chooses to confront the client. A nurse is caring for a client who has emphysema and has difficulty with mobility. 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. b. 4. Incorrect: This prescription is written correctly. 3. 3. a. c. Do not eat or drink anything the morning of the test Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. (Select all that apply.). Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 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. Schedule visiting times in two-hour increments so clients are not overwhelmed. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Client scheduled for a dressing change to foot ulcer. b. Make referrals to community services. d. Establishing the client's secondary medical diagnoses, b. 3. A nurse is preparing to move a client who is only partially able to assist up in a bed. b. Grape juice 1. Report of feeling pressure Furosemide 40 mg PO q.d. Which of the following actions is the priority for the nurse to include in the client's plan of care? It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). b. I will call the doctor and get the prescription a. I'll urinate a little then stop Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. 2. Which clients could be assigned to an LPN? Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. An Advance Directive includes a Living Will and a Medical Power of Attorney. The client is getting better. This is a task that can be delegated to the LPN/LVN. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? A nurse is planning care for a female client who has an indwelling urinary catheter. The cause of the fall may be cardiac, but the question does not indicate this. (Select all that apply.). (Select all that apply.) Client reporting a headache and has a fruity breath. b. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Nothing by mouth (NPO). d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. a. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Have a pen and paper handy 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). Incorrect: Teaching is outside the scope of practice for the LPN/LVN. c. The emphasis is on the client's complete recovery from the illness or injury The nurse would then start the 24 hour urine once the 1st void has been discarded. Try different methods of oral care on unresponsive clients to see what works best. b. a. A nurse is developing a plan of care for a client who practices Islam. Assign a nursing assistant to help the client with self-care activities. 1. A high concentration of carbon monoxide can cause death e. Talking with the client's partner, 79. 1. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. If a sentence is already correct, write CCC. Could you try contacting a support group The nurse who made the medication error should take which of the following actions first? It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. a. 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. b. Discuss the issue with the leader of the "best practices" committee. 208 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. A nurse has just finished a wound irrigation for a client who requires contact precautions. 2. Correct: The medical nurse can be assigned to this client. Correct: An LPN should be assigned clients with predictable outcomes. Announce the new changes at the monthly staff meeting. Include any relevant statements the client made about the ulcer There are a total of 10 adult clients. 3. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Select all that apply 3. Respite care allows the primary caregiver time away from day-to-day care responsibilities Monitor client for pain while assisting with ambulation. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. What task would be best to assign to the LPN/LVN? What interventions can the nurse delegate to the LPN/VN? Relief of urinary retention Ask client if they are eating small, frequent meals. Both of these clients are terminal. 3. Determine caregiver's stress level and coping strategies.
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