d. Complete an incident report, 70. Focusing 2. Serve food that have a hot/cold balance Select all that apply. Select all that apply Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. 3. Use adult diapers to prevent frequent clothing changes 3. Which of the following statements should the nurse identify as an indication that the client needs further teaching? This protein is released by cells in the stomach. Which client would be appropriate for the RN to assign to the LPN? 1. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Transfer essential medical record to the receiving facility. b. Which of the following explanations should the nurse provide? 5. b. I should call my doctor if I find it harder to concentrate 2. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. What is the best response by the charge nurse? Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. A charge nurse is observing a group of newly licensed nurses. Report of feeling pressure Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 4. b. Prepare a list of clients who could quickly be discharged or transferred. 4. Feed a client that had a stroke 3 months ago. It contains a blank and is followed by four answer choices. Documentation of what occurred, and the client's assessment is required in the nurse's notes. Which of the following should the nurse identify as an interpersonal variable? 4. a. Which of the following interventions should the nurse include? What information should the nurse include? 4. Fruity breath. d. What have you done in the past to cope with this issue? Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The other options may be correct but are not the best first action. 1. Allow families unlimited visitation around the clock to meet their schedules. 3. a. c. The client was restless and trying to get out of the bed all evening 3. Notify the nursing supervisor of the situation. Explain oral hygiene to a client receiving chemotherapy The nurse does not know the skills of the new UAP. This service began with the client's admission to the hospital a. b. This is normal for clients with hemorrhoids. The nurse considers various ideas submitted by team members. A charge nurse is making assignments for an oncoming shift. 4. They are likely to wait for others to initiate conversation 3. b. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. 4. d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. 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. b. The nurse is using which level of communication at this time? Incorrect: The nurse is responsible for monitoring a client. (Select all that apply.) An LPN/VN has been floated to the emergency room following a chemical plant explosion. If a sentence is already correct, write CCC. Delegate 2 nurses to work with the client. What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? Which of the following statements should the preceptor make? a. Hypotension Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. d. What have you done in the past to cope with this issue? Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. _____The house that we lived in for nine years has been sold. 2. The LPN should refuse the intervention. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. b. d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. 4., & 5. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Donning gloves and using a gauze pad to grasp and remove dentures 2. Teach the UAP to change surgical dressings. Ask the client to perform a return demonstration of insulin injection Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. 2. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. A nurse is teaching a client about the physical effects of chemotherapy. Placing a washcloth in the bathroom sink prior to cleaning. Take several shallow breaths during the procedure 3. Change the subject when the client behaves defiantly Incorrect: It is out of the UAP's scope of practice to administer medication. -Review a low-sodium diet for a client who has HTN 4. a. Sit side-by-side with the client What proposal would the nurse determine to best meet the needs of families and clients in long term care? b. Assigning tasks to an AP So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. 4. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. A nurse is admitting a client who has a partial hearing loss. a. I'll apply ankle to my ankle today and tomorrow 1. 4. A nurse is performing care activities for a client in the zone of touch that requires his consent. c. I will begin upon the client's admission to the facility Comatose client with end stage chronic obstructive pulmonary disease. The women's health charge nurse is making assignments for the next shift. a. Also, making a surgical bed for the client returning from surgery is a basic procedure. Initiate oxygen and IV lines as needed. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. d. Discussing intake and output Places the soiled linen in the floor before bagging it d. Wait to discuss the behavior in the presence of others, a. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). a. a. Client scheduled for breast reconstruction after mastectomy. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. a. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? 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. Accept assignment, documenting personal concerns regarding work conditions. Feedback Correct. Which client should be assigned to the most experienced nurse? The key word in the stem is first. Offer to take one of the clients. 5. The nurse is caring for four clients. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 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. 1. 1) Bathe a client who had an amputation 2 days ago. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. b. Which of the following communication techniques should the nurse use during this phase? Gather supplies to prepare room for isolation. Speak to the UAP to determine what happened with the feeding. Cardiac catheterization with a decreased pedal pulse below insertion site. A. 1. What client should the nurse assess first? The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. b. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. 6. A charge nurse is making client care assignments. a. It is not a routine task. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. (SATA) -Bathing a client who had an amputation 2 days ago. b. Perform catheterization when you recognize the urge to void 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. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. D. Incorrect. Which of the following actions should the nurse take? Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. Notify the charge nurse of the observations. Use double bagging to remove soiled linen from the client's room b. 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. A cardiac step down unit has requested float staff because of multiple impending admissions. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. b. Correct: The client has the right to be involved in the decision making of their care. Which of the following actions should the nurse take? The client would develop severe cramping. c. Environment The expected standard of care was strict bed rest), 96. Talk to each nurse about concerns related to assigned clients. Correct: The client may be experiencing a myocardial infarction and requires further assessment. a. 3. 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. It's unfortunate that I have to be in the hospital for this treatment A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). 1. 55. The client states, "I'm feeling a bit nervous today." Assist the float nurse with the clients case. c. To determine the client's electrolyte balance Underline the adjective clause in each sentence. Select all that apply. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Assigning blame for the changes to administration will not help staff adjust. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Assist ait to ambulate using a gait belt. d. Sleep apnea 2) Assist a client to ambulate using a gait belt. Correct: Did you notice the hint? Send a day's worth of medications with the client to the receiving facility. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. The client then states, "I have changed my mind and do not want to have the procedure done." 1. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. To focus on effective learning with this client, which of the following interventions should the nurse use? Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. 1. Respite care provides holistic support and care for a client who is terminally ill Incorrect: Informing is the same thing as teaching. d. Assault, b. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Aplastic anemia is a rare but serious condition. Which of the following should the nurse include as a criterion for applying restraints? a. 2. Removing the client's dentures b. 1. 4. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Patient safety must remain the priority. Which of the following activities should the nurse perform in this zone? Denial Yes! 2. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. butter, which contain 16 g of protein, 7 g of carbohydrates, Wrapping the dentures in tissue while the client sleeps d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. d. Routine acquisition of a urine specimen _________________ (magnanimous), a. generous The nurse on a large surgical unit needs to evaluate several clients returning from procedures. a. Auscultate breath should at least ever 2 hr The client asks the nurse, "Why do I need that? Remind the client to tell the nurse when he has to urinate 4. A nurse asks a client how he is feeling. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. Provide positive feedback to the UAP. 4. It is quicker to administer medications intravenously in the hospital a. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 1. 2. a. 2. Which clients should be assigned to the CNA? Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Gathering needed equipment and supplies is within the scope of duties for the UAP. Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. a. Which response by the LPN is appropriate in response to the inappropriate delegation? The nurse who made the medication error should take which of the following actions first? Narrative interaction Reach around the pack and open the top flap away from the body, 53. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. A nurse asks a client to share personal stories. 3. A nurse is caring for a client within the intimate zone of the client's personal space. 1. 3. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Battery Place the client in low Fowler's position A nurse enters an older adult client's room to insert a saline lock. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. The nurse voices his concern to the charge nurse. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. c. I'll bear weight on my ankle for 10 minutes every hour Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. 3. d. They disclose more personal information, a. Which of the following actions should the nurse include in the plan? (Select all that apply.) The LPN can monitor the wound and provide care to the PEG insertion site. The nurse is using which of the following therapeutic communication techniques? There are a total of 10 adult clients. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? and 16 g of fat. This action is a defensive intervention, and does not address the quarrelsome behavior. Hearing loss Nursing questions and answers. Which of the following actions indicates that the AP understands the principles of infection control? d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. d. Go to employee health services, b. Which of the following of Erikson's developmental stages should the nurse consider in the planning? A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 3. c. Complete an incident report The nurse should not lecture, scold or argue with the float nurse. c. Review another client's similar surgical experience c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. b. The nurse did not trust the new UAP. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. 5. Incorrect: This group of clients needs specialized care. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. Relief of urinary retention c. Explain the risks and benefits of the procedure 3. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. Question: A charge nurse is making client care assignments. 4. 3. Which of the following physiological responses to prolonged immobility should the nurse expect? c. When asking the client how he completes his ADLs 4. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. b. I will call the doctor and get the prescription 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. 1. 2. Provides safe, effective delivery of patient care in . Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. a. I will wear gloves when removing food from the freezer The nurse should perform which of the following activities in this space? The charge nurse is making client assignments for a neuro-medical floor. Select all that apply. What action should the nurse take after mistakenly administering the wrong medication? 5. Thus, the tasks involve successful management of the charge nurse's responsibilities. What options would be appropriate for the nurse to take? 4. Ambulating a client who is 2 days post vaginal hysterectomy 4. Discuss the assignment with another LPN. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. b. I will begin once the client's discharge order is written 4. The cleint's family asks the nurse for info about this type of care. 3. Removing the abdominal dressing 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. 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. Respite care allows the primary caregiver time away from day-to-day care responsibilities 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. c. Hallucinations at the onset of sleep, 65. A nurse who is on hormone replacement therapy. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. c. Providing anticipatory guidance to a client in crisis Teaching insulin self administration cannot be delegated to the LPN. Client with cast to right leg requiring pain medication. The RN with 8 years' experience in the Intensive Care Unit. 4. A nurse is assessing a client at a follow-up clinic for acute low back pain. Which of the following actions should the nurse take? A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. a. Bathtub with rails Electric cords behind the furnitrure Assist a client to ambulate using a gait belt. Currently, your census is 11, with one empty bed. a. Which task should the nurse take responsibility for completing? 1. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". c. Document in the client's medical record that she completed an incident report d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. This client should report an improved respiratory, not shortness of breath. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). Compartment syndrome could be developing which can impede circulation and cause nerve damage. b. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. The charge nurse should notify the nursing supervisor who will seek additional staff. This is an appropriate 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. c. Face shield Incorrect: Is phantom pain something that is unexpected with above the knee amputations? The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. a. The client is apparently stable and does not require any advanced assessment skills or specialized care. 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. 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. 6. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. 9. b. Which of the following actions should the nurse take prior to administering the tube feeding? Dexlansoprazole 30 mg PO daily. Plan all care to be completed in early morning to allow afternoon for visitation. 1., 2., 4., & 5. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? This includes medication enemas. In what order should the nurse see the clients? 3. 2. C. Review a low-sodium diet for a client who has hypertension. c. Distended bladder The charge nurse knows what client would be most appropriate for this LPN? c. Include intact skin at the wound edges in the culture Correct: An LPN/LVN's scope of practice includes tasks such as wound care. c. Malpractice Which of the following methods should the nurse plan to use? a. I'll sit with my knees lower than my hips c. Inform the surgical team to cancel the client's surgery Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. A nurse who is breastfeeding her 4 month old. Pain Obtain a urine specimen from a client with an indwelling Foley catheter. c. Nonfat milk Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? d. I have a set of my brothers' crutches in the basement I can also use, a. 2. If the client is unstable, the nurse would retain the role of measuring the vital signs. a. This is a diabetic clinic. c. Foot What is the appropriate assignment? A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. a. I'll provide more stimulation in his environment A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. A client requesting assistance packing his belongings for discharge later today.. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Report the incident to the charge nurse A nurse is teaching a client who has a history of falls about home safety. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. 1. This can prevent harm to client's. A nurse has completed an informed consent form with a client. (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. a. Select all that apply d. Reflection, c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation), 37.
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