The first vital sign check was performed by the nurse. Once the client is stable, the UAP could perform this task. a. 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. Dr. Frankenstein had seen himself as a(n) ?\underline{? Provide an adaptive feeding device for the client A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Providing hygiene care to a client who is HIV positive This is not a situation that requires the LPN to notify the primary healthcare provider. 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. c. I'll wear low heeled shoes from now on Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). The charge nurse should notify the nursing supervisor who will seek additional staff. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. a. 4. 2. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Select all that apply 1. Use double bagging to remove soiled linen from the client's room Gown The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Which clients should be assigned to the CNA? e. Throw rugs, 40. Understanding the charge nurse's role in staffing Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). 1. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. A charge nurse is observing a group of newly licensed nurses. Accept the client's behavior as confrontational. Perform the Heimlich maneuver Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. Client diagnosed with Guillain-Barre' who is receiving ventilator support. Refuse the assignment, being prepared for disciplinary action. NUR 212 Patient assignments.docx - M2.4: Making Client Care 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. Which response by the LPN is appropriate in response to the inappropriate delegation? As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. 2. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. This is an appropriate prescription. Which preoperative prescription should the nurse question? Incorrect: This client does not have a predictable outcome. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. Speak to the UAP to determine what happened with the feeding. Dexlansoprazole 30 mg PO daily. D. A nurse is caring for a client in the orientation phase of the nurse-client relationship. c. imaginary 5. 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. 2. 8. Vital sign measurement Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. Notify clients that the disaster plan has been put into effect. d. Let's wait until tonight to see if he continues his behavior, 63. *HURST REVIEW Qbank/Customize Quiz - Leadership d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. When determining if the client is eating a well-balanced diet Increased insulin production 3. Therefore, this client would not be a priority over a client who may be experiencing a MI. d. Droplet, d. Bend at the knees when picking up an object, 98. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? There is a trailing zero after the prescribed dose. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Gather supplies to prepare room for isolation. Invite staff to contribute ideas on scheduling changes. Notify the nursing supervisor of the situation. 4. 1. (Select all that apply.) The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Teaching insulin self administration cannot be delegated to the LPN. a. I'll urinate a little then stop A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 2. It's just not the right time for me to do this Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. (Select all that apply.) Select all that apply 3. The third client that should be sent back for treatment is the female client stating she has been raped. Oral surgeon Refuse the delegated intervention. Two nurses lifting the client under the shoulders c. Irrigating a client's abdominal wound 2. a. This determination is needed to assure client safety is being considered. A nurse is caring for a client who frequently attempts to remove his IV catheter. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. c. Document in the client's medical record that she completed an incident report 3. b. What interventions can the nurse delegate to the LPN/VN? a. Which action should the nurse interrupt the UAP from performing? nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. 1., 4., & 5. 2. b. 2. c. Discard any residual gastric contents Which of the following methods should the nurse plan to use? 4. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. Providing a passive response The RN with 2 weeks' experience on the postpartum unit. Which of the following client statements should indicate to the nurse the need for additional teaching? When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? 2. The situation should be explored before bringing the supervisor in on the situation. d. Discard the prepared medications and begin again after returning, d. I will wear synthetic clothing and woolen socks when using my oxygen (woolen and synthetic materials can generate static electricity and oxygen is a flammable gas - the client should wear cotton), 73. Which of the following actions should the nurse take? c. Changing a dressing, 78. 4., & 5. Twist at the waist when she moves an object to one side 1., 2., 3., & 4. }? benefactor of the world. 2. a. The charge nurse is making client assignments for a neuro-medical floor. Occupational therapist Nurses Report Sheet Template Nicu. 4. d. 216, 22. a charge nurse is making client care assignments for the day. which c. Palpating for pedal edema The nurse has received the change-of-shift report. 3. The nurse cannot allow the UAP to perform advanced tasks. Initiate oxygen and IV lines as needed. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. This is outside the scope of practice for the LPN/LVN. NUR 112 Practice Assessment Flashcards | Quizlet a. 2. 3. The nurse asks why the client needs to know this. The nurse chooses to confront the client. Incorrect: This group of clients needs specialized care. A nurse wants to find out a better way to perform oral care on unresponsive clients. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Which of the following actions should the nurse include in the plan? Which of the following findings indicates that the client is meeting this goal? Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). 5. Observe the client before taking further actions Correct: Communication is important in delegation, as is follow-up. A two-hour limit on visits discourages quality time. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. 3. Select all that apply 5. 3. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. Provides day to day direction and supervision to assigneddirect patient care staff . c. Washes and rinses her hands for 10 seconds, 11. 2. c. The nurse may serve as a witness to informed consent for organ donation "The client is weak on the right side, so please assist the client with dressing . c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. It's unfortunate that I have to be in the hospital for this treatment In which harmonic number n is the string vibrating? a. The nursing supervisor may be able to assist with client care until another nurse can come in to work. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. Bargaining M4 Client Care Assignment.pdf - Making Client Care Tenderness over the symphysis pubis Remember airway, breathing and circulation (ABCs). Ask the primary healthcare provider to suggest the best oral care procedure. 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. Thus, the tasks involve successful management of the charge nurse's responsibilities. Relief of urinary retention The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. 3. The nurse has been assigned four clients. Which of the following findings should the nurse identify as a safety risk? Sit side-by-side with the client Which of the following client statements indicates an understanding of the procedure? a. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Place in priority order. The client with chronic emphysema has expected shortness of breath. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. 2. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. 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. This would be out of the UAP's scope of practice. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Which of the following actions should this nurse take? If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29. c. Helping the client into the shower Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Ambulating a client who is 2 days post vaginal hysterectomy Incorrect: This client is exhibiting early signs of increased intracranial pressure. b. Numbness The nurse could definitely be part of the committee. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. A client has been admitted with folic acid deficiency anemia. d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. A nurse is caring for a client who has a wound infection. b. I will keep the fluorescent ceiling light on in my room at night A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. This service began with the client's admission to the hospital, 18. A nurse is caring for a client whose partner asks to speak with the nurse. A charge nurse is planning client activities for the day. b. A nurse is caring for a client within the intimate zone of the client's personal space. 1., 3, & 4. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. 2. 2. The nurse who made the medication error should take which of the following actions first? Semi-formed stools are great news! c. Check to see if the suction equipment is working d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. 4. 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. b. 2. 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). Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Refuse the overtime assignment, being prepared for disciplinary action. a. Clarification Changing the subject (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 b. 3. Administer tap water enemas until clear at 6 AM. An LPN/VN has been floated to the emergency room following a chemical plant explosion. The other options may be correct but are not the best first action. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Reach around the pack and open the top flap away from the body 4. Obtain a bedside commode for the client's use For Option #3, you may have recognized MgSO4 as being magnesium sulfate. 3. a. A nurse is orienting a new assistive personal (AP) to the unit. What information should the nurse include? Ask the client to perform a return demonstration of insulin injection b. c. Complete an incident report One important aspect is encouraging the flow of ideas between management and staff members. a. 55. Notify the board of nursing (BON) that the float nurse is an alcoholic. a. Incorrect: This again is assessment which is the role of the RN only. This is the most stable of the four clients which places this client last to be seen. A nurse is assessing a client who has narcolepsy. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? A person can be designated to make medical decision in the event the client cannot. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. The nurse is reviewing some clients' prescriptions. 4. A nurse just back from maternity leave. 4. Elderly clients have special fluid and electrolyte issues after a fall. Charge Nurse II- CNII - jobs.freseniusmedicalcare.com d. Services are centered in long-term care facilities, a. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. It happened so long ago - just get over it!" Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. c. Provide the client with a diet high in protein a. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. A nurse instructs a female client about collecting a midstream urine sample. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? Try different methods of oral care on unresponsive clients to see what works best. 3. Select all that apply 6. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. 1. Elevating the head of the bed 30- 40 for the client post thoracotomy a. I will wear gloves when removing food from the freezer Charge nurses have integral roles in healthcare organizations. c. Review the client's progress toward personal objectives 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. A school-aged child with a fractured femur who is in balanced suspension traction. 2. This is normal for clients with hemorrhoids. b. Urinary frequency for several days Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. a. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. 3. Remind the client to tell the nurse when he has to urinate Incorrect: Medications are not transferred with the client to a new facility. 2. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Teach caregivers memory enhancement aids. Feed the client after warming the food. Lumbar puncture reporting a headache. What was the hint? d. Determine if the client uses hearing aids, b. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. is a new graduate in orientation. The nurse has another priority. a. This stage involves constructive efforts on the part of the group members To confirm the placement of the NG tube Drag and Drop the items from one box to the other. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Client scheduled for breast reconstruction after mastectomy. c. Respite care helps relieve pain and promote comfort a. Documentation is a communication tool for the interprofessional health care team. Which of the following actions is an example of a violation of confidentiality? Client two days post percutaneous endoscopic gastrostomy (PEG) placement. The client then states, "I have changed my mind and do not want to have the procedure done." d. Go to employee health services, b. The assignment process requires constant evaluation and reevaluation of information and priorities. Select all that apply. d. Place the tablet directly into a medication cup, 36. c. Inflate the balloon when the urine flow stops 1. A nurse is adhering to standard precautions while caring for a group of clients. Discuss the competency of the surgeon A nurse is filling out an incident report after finding a client lying on the floor. A client requesting assistance packing his belongings for discharge later today., Assign more daily tasks to the UAP. This individual should be provided appropriate comments of appreciation for this accomplishment.
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