Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Which of the following actions should the nurse take? 2. 3. c. Discard any residual gastric contents b. I can detect the presence of carbon monoxide by a metallic odor This stage is when testing occurs to identify boundaries of interpersonal behaviors b. I will bear the weight of my body on my hands Client with a T-5 spinal cord injury beginning rehabilitation therapy. 3. 2. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. c. When asking the client how he completes his ADLs 2. "The client is weak on the right side, so please assist the client with dressing . Which nursing intervention should the charge nurse implement? A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. Empty the drainage bag at least every 8 hrb.) A post-cardiac catheterization needing assistance with bedpan. Which client can be assigned to the LPN? Assist a client to ambulate using a gait belt. An experienced person who can research "best practice" regarding the issue is needed. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. A charge nurse is making assignments for an oncoming shift. Accept the client's behavior as confrontational. 6. Which of the following nontherapeutic communication techniques is the nurse using? 2. A nurse is caring for a client who states, "I have got to get out of this hospital! Monitor client for pain while assisting with ambulation. Remove all metal necklaces 1., 2., 3., & 4. 5. 1. a. d. Complete an incident report, 70. 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. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Most of the following sentences contain errors in the use of modifiers and comparisons. c. Gender Relief of urinary retention This is a task that can be delegated to the LPN/LVN. Assist ait to ambulate using a gait belt. 5. b. (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. 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. . 3. Speak to the UAP first and then decide if a between meal supplement is needed. c. Changing a dressing, 78. 4. 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. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. Two hours . Female client stating she has been raped. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Invite staff to contribute ideas on scheduling changes. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Respite care provides holistic support and care for a client who is terminally ill 2. 1. d. Establishing the client's secondary medical diagnoses, b. 1, 3 & 5. Focusing This referral would be appropriate. The RN requests reassigning at least one of the clients to another nurse. 2. 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. Following a large hurricane, multiple clients arrive at the emergency room for treatment. 2. A nurse is preparing a sterile field. Which of the following should the nurse include as a criterion for applying restraints? A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. The RN with 2 weeks' experience on the postpartum unit. d. Talk with the client's partner, b. Which client would be appropriate for the RN to assign to the LPN? The nurse chooses to confront the client. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. When a family member asks how respite care can help, which of the following responses should the nurse provide? Correct: An LPN should be assigned clients with predictable outcomes. a. Which of the following actions is the priority for the nurse to include in the client's plan of care? In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Determining the client's length of stay To remove gastric acid that might cause dyspepsia A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. All these clients have a GI problem. Incorrect: This prescription is written correctly. c. Inflate the balloon when the urine flow stops Documentation of what occurred, and the client's assessment is required in the nurse's notes. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. 212 Only the state Board of Nursing can legally determine the LPN's scope of practice. 2. b. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. 1. Also, making a surgical bed for the client returning from surgery is a basic procedure. It is quicker to administer medications intravenously in the hospital We do not know the extent of her injuries based on what the option tells us. A nurse who is 10 weeks pregnant. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. The unit is short one staff member and will receive a nurse from the medical surgical unit. This client is not the nurse's first priority. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). The expected standard of care was strict bed rest), 96. d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. 6. 3. 1., 3, & 4. Confrontation should occur in the presence of a charge nurse or supervisor. A nurse is teaching a client about carbon monoxide poisoning. e. Talking with the client's partner, 79. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. c. Hallucinations at the onset of sleep Perform range of motion (ROM) exercises at least 2-3 times daily Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. b. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Incorrect: The nurse cannot assign teaching to the UAP. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. The client with chronic emphysema has expected shortness of breath. d. Perception a charge nurse is making client care assignments for the day. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. a. 1. b. Notify the board of nursing (BON) that the float nurse is an alcoholic. 4. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. b. Wash the tablet off with alcohol and place it in a clean medicine cup is a new graduate in orientation. (SATA) -Bathing a client who had an amputation 2 days ago. Feed the client after warming the food. Which of the following actions should the nurse take? The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Denial When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. 1. Correct: The client who has a cast and requires pain medication is a stable and predictable client. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. It contains a blank and is followed by four answer choices. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. b. 2. d. I have a set of my brothers' crutches in the basement I can also use, a. Encourage client to express grief related to loss of independence. Which of the following instructions should the nurse include? The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? The area surrounding the insertion site feels warm to the touch The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. For which of the following actions should the nurse intervene? a. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 3. Make referrals to community services. Bargaining Decreased RBC production Tenderness over the symphysis pubis 3. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Select all that apply The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Anyone over age 18 can have an Advanced directive. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. d. Anger, b. In option #4, we see that the leading zero is missing from the prescription. 1., 2., 4., & 5. Assist a client to ambulate using a gait belt The nurse received a client following surgery 8 hours ago. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A nurse is planning to discharge a client who has quadriplegia to his home. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? The client with cystitis is stable and has a predictable outcome. Which of the following is the priority action by the nurse? 4., & 5. Gather and apply dressings to open wounds. 4. Each state BON differs in that also some have treatment programs they administer themselves. 4. a. 4. d. Place the tablet directly into a medication cup, 36. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Include any relevant statements the client made about the ulcer, 64. 2. 2. Correct: Communication is important in delegation, as is follow-up. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? 3. Write the letter of your choice on the answer line. 2. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Incorrect: What seems to be going on with this client? It happened so long ago - just get over it!" A nurse is developing a plan of care for a client who does not speak the same language as the nurse. This is normal for clients with hemorrhoids. Select all that apply An Advance Directive includes a Living Will and a Medical Power of Attorney. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. b. A nurse is caring for a client who is postoperative following abdominal surgery. The nurse prefers to check all vital signs on all clients. Remind the client to avoid tight fitting clothes. 4. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 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. However, there are some basic points which are standard among all facilities. The third client would be the one needing a dressing change. 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. 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. 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 A nurse wants to find out a better way to perform oral care on unresponsive clients. d. They disclose more personal information, a. The nurse voices his concern to the charge nurse. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter (Select all that apply.). Well, do you see the q.d.? Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. What is the most appropriate action by the charge nurse? c. Visual observation for nonverbal signs of pain c. Explain the risks and benefits of the procedure Incorrect: This group of clients needs specialized care. A client diagnosed with rheumatoid arthritis needing discharge teaching. Which of the following RNs should not be assigned to this baby? Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which of the following responses should the nurse make? The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Right forearm c. I should purchase a carbon monoxide detector for my home b. Besides, a charge nurse is a leader on the floor and should possess . A nurse is assessing a client at a follow-up clinic for acute low back pain. Which task would be appropriate for the nurse to assign to an LPN/VN? Could you try contacting a support group b. Notify clients that the disaster plan has been put into effect. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Focus on the client's present circumstances instead of his personal stories 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. 3. Documentation is a communication tool for the interprofessional health care team. 4. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. The client must understand the need for restraints Select all that apply 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. Which of the following physiological responses to prolonged immobility should the nurse expect? 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. Report of feeling pressure The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Evaluate pain relief after narcotic administration. 3. Incorrect: This client does not have a predictable outcome. A client with epilepsy reporting an odd smell in the room. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. The cleint's family asks the nurse for info about this type of care. A nurse instructs a female client about collecting a midstream urine sample. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Now, in Option #2, we see a dangerous prescription. 1. Which actions should be instituted by each unit's charge nurse? 2. Which preoperative prescription should the nurse question? 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 nurse is caring for a client who frequently attempts to remove his IV catheter. b. The body needs vitamin B12 to make red blood cells. 3. Which of the following instructions should the nurse give to the client prior to the procedure? A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. 3. c. Initiate a liquid diet for the client 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. Autonomy vs shame and doubt b. Irrigate the NG tube with 100 mL of sterile water d. When asking if the client took his medications this morning, 82. A nurse has completed an informed consent form with a client. Select all that apply b. 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. A nurse is preparing medication for a client when another client has an emergency. 2. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. A nurse is implementing direct nursing care for a group of clients in an acute care facility. 3. 2. a.) d. Discussing intake and output For Option #3, you may have recognized MgSO4 as being magnesium sulfate. Review a low-sodium diet for a client with hypertension. Evaluate client's safety risk factors. c. Palpating for pedal edema Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Try different methods of oral care on unresponsive clients to see what works best. This would be out of the UAP's scope of practice. Remember airway, breathing and circulation (ABCs). Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". 3. The nurse is planning care for a client admitted with Alzheimer's Disease. d. Motor impairment, 84. 2. a. Broth What is the primary factor for the charge nurse to consider when delegating care? Show client who has conjunctivitis how to clean the eyes. a. 3. Education Have a pen and paper handy b. The RN with 8 years' experience in the Intensive Care Unit. The last client would be the one needing dietary education. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The infusion rate has stopped but the tubing is not kinked In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. The charge nurse is developing patient care assignments for the evening shift and needs to assign clients to a licensed practical nurse/licensed vocational nurse (LPN/LVN) and a certified nursing assistant (CNA). The nurse should do this when repositioning is needed. 1. 1. Only a plain enema or soap enema can be given by the UAP. 3. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. This schedule may leave some clients too exhausted to visit with family. Gather supplies to prepare room for isolation. A client post pacemaker insertion, awaiting discharge instructions. The client's self-report of pain severity 1. Dexlansoprazole 30 mg PO daily. Where on the body is each type of skin found? Incorrect: The nurse is responsible for evaluating a client. 1. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Elderly client who fell and fractured the left femoral neck. Inform the client of the need to avoid irritants such as carbonated beverages. 1. c. Physical therapist Select all that apply. 1. b. b. 2. The nurse is using which level of communication at this time? Which of the following statements should the nurse identify as an indication that the client needs further teaching? The best practice committee works to improve clinical practice based on current research. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. 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. Everything will be okay Observe the client before taking further actions A nurse asks a client how he is feeling. The client states, "I'm feeling a bit nervous today." ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. a. Hypotension d. Water heater temp 54.4 C (130 F) It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. Which of the following findings associated with urinary retention should the nurse expect? 2. 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).
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