Female client stating she has been raped. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 1. b. This action is a defensive intervention, and does not address the quarrelsome behavior. c. The restraints should promote the client's safety and prevent injuries This client can wait until the others are treated. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? 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. d. Determine if the client uses hearing aids, b. 1. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. 1. A nurse is caring for a client who has a hip fracture that requires surgical repair. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Checking capillary refill beneath the client's fingernail 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. Provide the client with a diet high in protein However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. b. Assigning tasks to an AP d. I will place a bath seat in my shower to use when I bathe, b. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. Dentures should be stored in a denture cup. Which group of clients should she assign to the medical surgical nurse? Which of the following actions is the priority for the nurse to include in the client's plan of care? Sit side-by-side with the client 2. 2. Where on the body is each type of skin found? (Select all that apply.). Serve food that have a hot/cold balance A charge nurse is observing a group of newly licensed nurses. Each state BON differs in that also some have treatment programs they administer themselves. c. Can you tell me why you chose me? a. 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. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. d. Explain oral hygiene to a client receiving chemo The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). d. Bend at the knees when picking up an object, 99. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. It is within the LPNs scope of practice to administer antibiotics. 4. 4. 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. A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following instructions should the nurse give to the client prior to the procedure? In what order should the nurse assess assigned clients following shift report? 3. 1. A school-aged child with a fractured femur who is in balanced suspension traction. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. b. Thus, the tasks involve successful management of the charge nurse's responsibilities. 2. a. a. Reposition the client every 3 hr d. Anger, b. Which of the following findings should the nurse identify as a safety risk? 1. 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. d. Mask, 83. Elderly clients have special fluid and electrolyte issues after a fall. 2. d. Providing information, a. 3. 2. c. Offer the client personal thoughts and beliefs 3. Remind the client to avoid tight fitting clothes. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. b. 3. 4. 2. Write N next to the nonessential clauses and E next to the essential clauses. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. Document what the nurse believes was the cause of the ulcer development Plan all care to be completed in early morning to allow afternoon for visitation. b. I'll rewrap my ankle starting from the knee down d. Do you think crying will help? A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. c. Rephrase statements the client does not hear Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Elderly client who fell and fractured the left femoral neck. The facility has insurance that will cover malpractice litigation To confirm the placement of the NG tube The nurse should not be assigned to provide care if impairment is suspected. This stage involves constructive efforts on the part of the group members c. The emphasis is on the client's complete recovery from the illness or injury Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Which client should be assigned to the most experienced nurse? Refuse the overtime assignment, being prepared for disciplinary action. Describe the types of machining operations that can be performed on a lathe. A client on a surgical unit frequently quarrels with the staff. c. I will make sure my visitors smoke outside This could indicate a worsening of this client's condition. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? b. What action should the nurse implement first to ensure client safety? Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. When staff do not feel vested in any new process, there is a sense of underappreciation. c. Holds the soiled linen against her body while carrying it to the linen bag Reporting laboratory findings to a member of the client's family 2. Incorrect: The RN is responsible for teaching. 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. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department 5. b. b. 5. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. b. 3. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 4. 2. a. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 1. Risperidone .5 mg PO daily 5. The nurse caring for the client at the time of death requests organ donation 1., 3, & 4. Incorrect: Moistening the dentures will ease insertion. 1. c. 214 a. a. c. Environment Changing a colostomy bag. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. 5. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. 4. Correct: Traction should never be relieved without a primary healthcare provider's prescription. 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 nurse is caring for a client who has emphysema and has difficulty with mobility. 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. Incorrect: This group of clients needs specific teaching. A nurse is preparing a sterile field. Select all that apply. Read all the current literature related to oral care on unresponsive clients. 5. 2. b. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. The below statement corresponds to a numbered sentence in the passage. 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. The client asks the nurse, "Why do I need that? 2. 1. Provides day to day direction and supervision to assigneddirect patient care staff . A nurse is filling out an incident report after finding a client lying on the floor. 4. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? b. The client post PEG placement is stable. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 2. In which situation should the nurse consult the client's advanced directive? 3. Which of the following actions should the nurse take? Removing the client's dentures 2. Monitor for GI upset 30 minutes after meals. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. Initiate oxygen and IV lines as needed. Which of the following statements should the nurse make? Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 1. a. Use double bagging to remove soiled linen from the client's room 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. 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. Have another nurse guard the medication preparations until the nurse returns Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. d. Proceed with the preparation of the patient's surgical procedure, 15. b. Decreased or suppressed respiration are priority. A nurse is discussing the norming stage of the group development process with a student nurse. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. a. b. I'll use the cleansing wipes from the front to back Ask for any staff objections to rearranging work hours. Asking for an explanation The client is getting better. A nurse is administering a cold therapy application to a client. Hanging a new bag of total parenteral nutrition (TPN). Administer sodium polystyrene sulfonate enema. Assigning blame for the changes to administration will not help staff adjust. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. This individual should be provided appropriate comments of appreciation for this accomplishment. Patient safety must remain the priority. Occupational therapist Identify and assess each incoming client. 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. The nurse should do this when repositioning is needed. 3. Write the letter of your choice on the answer line. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. 3. 4. a. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? c. Palpating for pedal edema 3. 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. d. They disclose more personal information, a. 4. Which of the following actions should the nurse take? _________________ (magnanimous), a. generous Select all that apply. a. The RN with 10 years' experience pulled from the ER. 1. c. Use intermittent eye contact For which of the following actions should the nurse intervene? d. Highly concentrated urine, 91. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Select all that apply. c. Review the client's progress toward personal objectives The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. Normally, red blood cells are flexible and round, moving easily through blood vessels. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Alcoholic Anonymous There will likely be both physical and emotional injury that needs attention, which places this client third. Which client should the nurse see first? A nurse is preparing to obtain a blood specimen from a client by venipuncture. A nurse is preparing medication for a client when another client has an emergency. Elderly client admitted 30 minutes ago with reports of constipation for four days. 2. d. Go to employee health services, b. a. Assessing this client and titrating the diltiazem requires the skills of an RN. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. 5. Making client care assignments As the RN charge | Chegg.com Science Nursing Nursing questions and answers Making client care assignments As the RN charge nurse, you are preparing to make assignments for the oncoming shift in the medical-surgical unit. A nurse is assessing a client who is experiencing prostatic hypertrophy. Most of the following sentences contain errors in the use of modifiers and comparisons. The third client that should be sent back for treatment is the female client stating she has been raped. Which of the following actions should the nurse take to assist the client with feeding? Which of the following actions should the nurse include in the plan? What options would be appropriate for the nurse to take? Which clients should be assigned to the CNA? which client would be an appropriate care assignment for this lpn? This service focuses on teaching the primary caregiver to meet the client's needs 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. a. Fruity breath. Notify the board of nursing (BON) that the float nurse is an alcoholic. a. d. Motor impairment, 84. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Comatose client with end stage chronic obstructive pulmonary disease. 4. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. 76. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A nurse caring for a client is using active listening skills. b. This documentation should go to your manager. 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. In option #4, we see that the leading zero is missing from the prescription. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Confrontation should occur in the presence of a charge nurse or supervisor. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. c. Decreased sodium excretion Which of the following actions is an example of a violation of confidentiality? Feed a client that had a stroke 3 months ago. The nurse considers various ideas submitted by team members. This is outside the scope of practice for the LPN/LVN. It is quicker to administer medications intravenously in the hospital Charge nurses have integral roles in healthcare organizations. A goal for this client is to use proper body mechanics at all times. Measure urine output when client voids. Which of the following statements should the nurse make? Complete a client assignment sheet for the oncoming staff. Provide an adaptive feeding device for the client c. Raised toilet seats 5. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. a. I'll apply ankle to my ankle today and tomorrow A nurse is caring for a client who is about to have a colonoscopy. c. Industry vs inferiority a. Client who has multiple injuries from a motor vehicle accident. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. Correct: Communication is important in delegation, as is follow-up. a. 3. Empty the drainage bag at least every 8 hrb.) Select all that apply b. c. Include intact skin at the wound edges in the culture A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. 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 client reports constipation for 4 days which may be an indication of worse problems. A person can be designated to make medical decision in the event the client cannot. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. 2. Documentation is a communication tool for the interprofessional health care team. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. 3. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. 3. 3. b. Negligence and 16 g of fat. 1. 1. Try different methods of oral care on unresponsive clients to see what works best. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. 3. 1. Furosemide 40 mg PO q.d. This is likely cholelithiasis, which will need to be checked out. Licenced practical nurses are a little less educated than registered nurses. 2. Assist the float nurse with the clients case. Measuring vital signs A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. B. 1. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Incorrect: Informing is the same thing as teaching. a. 1. b. Grape juice 4. b. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. What information should the nurse include? Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. b. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? 1. Client who is a diabetic experiencing diabetic neuropathy. What interventions can the nurse delegate to the LPN/VN? The client states, "I'm feeling a bit nervous today." The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). A nurse is planning care for a female client who has an indwelling urinary catheter. Place the client in a lateral position A nurse is admitting a client from a long-term care facility. c. I should purchase a carbon monoxide detector for my home a. Which of the following statements by the student indicates understanding of the discussion? 2. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. 1. What proposal would the nurse determine to best meet the needs of families and clients in long term care? The healthcare team should recognize the client as the center of the team. Which of the following actions should the nurse take regarding informed consent? There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. What client should the nurse assess first? A nurse is assessing a client at a follow-up clinic for acute low back pain. 5. c. I will inspect my crutches everyday for signs of wear 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. 3. c. Depression 1. It's unfortunate that I have to be in the hospital for this treatment In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. b. d. Establishing the client's secondary medical diagnoses, b. If the client is unstable, the nurse would retain the role of measuring the vital signs. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. a. A nurse is caring for a client who is scheduled for an elective surgical procedure. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 77. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. c. Irrigating a client's abdominal wound After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? 3. Right forearm The nurse received a client following surgery 8 hours ago. 1., 2., 3., & 4. Client reporting a headache and has a fruity breath. d. I shouldn't advice you about what is ultimately a personal decision, b. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? 1. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Left upper forearm Incorrect: The client does need to have food; however, there is another action that should be performed first. c. Palpating for pedal edema The first vital sign check was performed by the nurse. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 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 charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. This situation is considered an external disaster which means the hospital will be expecting multiple victims. c. Providing anticipatory guidance to a client in crisis 4. c. I will cover the catheter so he cannot see it Respite care provides holistic support and care for a client who is terminally ill 3. 2. 1. 2. 1. which client would be most appropriate to assign a licensed practical nurse (lpn)? Feedback 4. c. Malpractice Which of the following actions by the nurse is considered an indirect nursing care activity? Give magnesium citrate 296 mL at 3 PM today. Which of the following actions should the nurse take? Drag and Drop the items from one box to the other. Which of the following findings indicates that the client is meeting this goal? The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. d. Discussing intake and output