Which of the following items should the nurse include on the lunch tray? The client reports constipation for 4 days which may be an indication of worse problems. b. Performing passive range of motion (ROM) on the client with right sided paralysis. In order to reorganize staffing, the nurse manager should initiate which action first? d. When asking if the client took his medications this morning, 82. 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 c. Document in the client's medical record that she completed an incident report Disconnect client's nasogastric (NG) tube suction to allow ambulation. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. This task cannot be delegated to the LPN/LVN. 3. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Assign a nursing assistant to help the client with self-care activities. This service focuses on teaching the primary caregiver to meet the client's needs A nurse is adhering to standard precautions while caring for a group of clients. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? In option #4, we see that the leading zero is missing from the prescription. Right forearm It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 2. Providing a passive response 2. c. I'll wear low heeled shoes from now on Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Which group of clients should she assign to the medical surgical nurse? Refuse the delegated intervention. Reporting laboratory findings to a member of the client's family Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. c. Palpating for pedal edema A nurse is developing a plan of care for a client who practices Islam. 1. assignmentcafe.com - A charge nurse is making assignments for nursing 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. c. The client's culture d. Message, 67. 4. Client to receive dietary education. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Thus, the tasks involve successful management of the charge nurse's responsibilities. d. Transporting a cerebrospinal fluid specimen to the lab Which of the following responses should the nurse provide? 4. b. 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. Plan all care to be completed in early morning to allow afternoon for visitation. A nurse who is on hormone replacement therapy. 1. Incorrect: The charge nurse does not have to assess every client. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. 1. Incorrect: This group of clients needs specific teaching. 3. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". d. Remove and reinsert the NG tube, a. b. I'll use the cleansing wipes from the front to back a. Checking capillary refill beneath the client's fingernail c. Review another client's similar surgical experience d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. b. 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Which of the following responses should the nurse make? Elderly clients have special fluid and electrolyte issues after a fall. d. Proceed with the preparation of the patient's surgical procedure, 15. Speak to the UAP to determine what happened with the feeding. The nurse is reviewing some clients' prescriptions. Which of the following instructions should the nurse give to the client prior to the procedure? a. It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. Encourage clients and families to develop mutually appropriate visitation times. Administering IV pain medication to a two day post op client. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. b. I should call my doctor if I find it harder to concentrate 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. c. Tie linen bags securely at the top Select all that apply. Incorrect: Atrial fibrillation places the client at risk for blood clots. Oral surgeon This client is stable and predictable. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 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. . 1. The nurse is responsible for the assessment of all vital signs of post-op clients. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. 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. b. Irrigate the wound with an antiseptic prior to obtaining the specimen The LPN/LVN can reinforce teaching. 8. Underline the adjective clause in each sentence. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. A client with an above the knee amputation reporting phantom pain. 3. b. Have another nurse guard the medication preparations until the nurse returns Select all that apply Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 3. Bargaining a. 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. 1. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. 2. a. Bathtub with rails b. I will keep the fluorescent ceiling light on in my room at night Client with cast to right leg requiring pain medication. 1. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Which of the following actions should the nurse take to assist the client with feeding? c. Malpractice This is an appropriate and safe action for the unlicensed nursing assistant to do. Select all that apply Temporary urinary retention (common for clients to develop after removal), 90. a. Select all that apply. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Select all that apply. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. Which of the following actions is the nurse's priority? The client is considered unstable until assessed by the nurse. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. d. Custard Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? Protective 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. a. 5. a. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. 4. Which of the following approaches should the nurse use when using confrontation? A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 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. Which prescription should the nurse question and have corrected? Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? Client diagnosed with inoperative brain tumor who is confused. 4. e. an open perineal wound, 92. (Select all that apply.) Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. 4. Ambulating a client who is 2 days post vaginal hysterectomy 2. Currently, your census is 11, with one empty bed. They are more direct when discussing issues Collecting I & O totals for unit clients at the end of shift. This schedule may leave some clients too exhausted to visit with family. d. Wait to discuss the behavior in the presence of others, a. 1. 2. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Correct: Disconnecting NG tube suction is an appropriate task for the UAP. Incorrect: The nurse is responsible for monitoring a client. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. 4. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. d. Explain oral hygiene to a client receiving chemo Review a low-sodium diet for a client who has hypertension. b. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. The nurse has just completed a 12 hour shift. 4. Select all that apply. 1. d. Voided 30 mL frequently, 48. A nurse is performing care activities for a client in the zone of touch that requires his consent. Initiate oxygen and IV lines as needed. The client asks about his medications and their effects. Notify the surgeon that the client wishes to withdraw informed consent for the procedure Relief of urinary retention c. The nurse may serve as a witness to informed consent for organ donation Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). c. Shivering Nurses dependent on drugs or alcohol can harm clients. The client says, "go away, no one can help me." A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. Jooble - LVN Charge Nurse - SIGN-ON BONUS $2500 a. I'll urinate a little then stop A post-cardiac catheterization needing assistance with bedpan. However, it remains true pain for this client and the client would need intervention to help manage this pain. Select all that apply. c. I will place an area rug at the entry of my bathroom This client needs careful monitoring and specialized care. 2. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. (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 d. Anger, b. 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? A nurse is planning care for a female client who has an indwelling urinary catheter. b. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Return any fresh linen not used for a client to the linen supply area A client with COPD complaining of shortness of breath on exertion. 1. 3. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. Select all that apply e. Feed a client who had a stroke 3 months ago, 31. 3. d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. A client receiving a blood transfusion that requires monitoring. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 2. Dentures should be stored in a denture cup. butter, which contain 16 g of protein, 7 g of carbohydrates, Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. 2. This would be an acceptable task to assign to the UAP. The client with cystitis is stable and has a predictable outcome. Besides, a charge nurse is a leader on the floor and should possess . Photo comes from the Greek word for light. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Ask the client to perform a return demonstration of insulin injection Prepare a list of clients who could quickly be discharged or transferred. a. b. 4. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 4. d. Motor impairment, 84. One important aspect is encouraging the flow of ideas between management and staff members. Compartment syndrome could be developing which can impede circulation and cause nerve damage. Incorrect: The nurse retains the responsibility for the delegated task. 5. 3. 3. c. I'll bear weight on my ankle for 10 minutes every hour 3. c. Hold an object away from her body as she lifts it A client with exacerbation of COPD reporting dyspnea. Fundamentals Practice Flashcards | Quizlet a. A nurse caring for a client is using active listening skills. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. A nurse is caring for a client who is immobile. with this question, the nurse is using which of the following communication techniques? Which of the following nontherapeutic communication techniques is the nurse using? Richied5864 Richied5864 . Which of the following interventions should the nurse include? Turning off continuous tube feeding to reposition a client, then turning the feeding back on. What is the best first action for the nurse to take in order to achieve this goal? 4. Client scheduled for a dressing change to foot ulcer. 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. The RN with 8 years' experience in the Intensive Care Unit. a. Auscultating heart sounds b. Assess the client 1. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Review the action of insulin therapy e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. c. I will inspect my crutches everyday for signs of wear a. Gloves Assist the float nurse with the clients case. A charge nurse is making assignments for an oncoming shift. This is a task that can be delegated to the LPN/LVN. Aplastic Anemia Support Group. Discuss the issue with the leader of the "best practices" committee. a. c. Washes and rinses her hands for 10 seconds 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. d. The nurse has already considered alternatives to restraints, a. A client diagnosed with rheumatoid arthritis needing discharge teaching. A nurse is caring for a client who has a mental health disorder. An experienced person who can research "best practice" regarding the issue is needed. A client requesting assistance packing his belongings for discharge later today., Accept assignment, documenting personal concerns regarding work conditions. The nurse received a client following surgery 8 hours ago. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. b. 4. A nurse is caring for a client who has limited hand movement. Solved A charge nurse is making client care assignments. | Chegg.com Incorrect: Informing is the same thing as teaching. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. 2. What is the appropriate assignment? CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. c. Hallucinations at the onset of sleep 3. A nurse is caring for a client whose partner asks to speak with the nurse. b. e. Suctioning a client's new tracheostomy tube, 93. 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. The charge nurse should notify the nursing supervisor who will seek additional staff. b. 5. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. 2. Estimate the number of Calories in two tablespoons of peanut UAPs can assist with elimination and are taught how to measure output. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Incorrect: The RN is responsible for assessment and evaluation. Drag and Drop the items from one box to the other. 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. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. 2. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. c. I will make sure my visitors smoke outside Convenience for the nursing staff or the client's family Which of the following statements should the nurse identify as an indication that the client requires further clarification? A lack of rapid eye movement (REM) sleep The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. 1. A nurse is caring for a client who expresses anxiety about his impending surgery. Evaluate pain relief after narcotic administration. (Select all that apply.) The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. 1. 4. Temporary urinary retention 3. 2. Client prescribed antibiotics for cystitis. Notify the charge nurse of the observations. The nurse is using which level of communication at this time? d. Voided 30 mL frequently 1. Incorrect: This is not completely practical for everyone. d. Routine acquisition of a urine specimen Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. Perform range of motion (ROM) exercises at least 2-3 times daily The nurse does not know the skills of the new UAP.
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