d. I have a set of my brothers' crutches in the basement I can also use, a. Select all that apply. What is the best care assignment for this client? 1. 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. The nurse voices his concern to the charge nurse. Monitor for GI upset 30 minutes after meals. Allow families unlimited visitation around the clock to meet their schedules. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. 3. 1. Nothing life threatening. 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. Discuss the issue with the leader of the "best practices" committee. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Delegate 2 nurses to work with the client. d. Proceed with the preparation of the patient's surgical procedure, 15. Incorrect: This client does not have a predictable outcome. Decreased or suppressed respiration are priority. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. The nurse would then start the 24 hour urine once the 1st void has been discarded. A high concentration of carbon monoxide can cause death Which of the following actions is the priority for the nurse to include in the client's plan of care? The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? 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. 2. 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. c. There is fluid leaking around the insertion site a. Clients over the age of 65 must have a saline lock according to facility policy c. Review the client's progress toward personal objectives }? benefactor of the world. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. The charge nurse might not have realized all the responsibilities of taking this team of clients. d. Discussing intake and output A nurse is administering a cold therapy application to a client. Assist ait to ambulate using a gait belt. 3. The third client that should be sent back for treatment is the female client stating she has been raped. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. The nurse did not trust the new UAP. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. 1. Which of the following actions should the nurse take first? Which of the following types of torts has the nurse committed? b. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. 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. 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. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. a. Clarifying A nurse is preparing to move a client who is only partially able to assist up in a bed. 3. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 3. 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. Ask the charge nurse to evaluate the intervention. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Try different methods of oral care on unresponsive clients to see what works best. Gown 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. A nurse is assessing a client who has narcolepsy. The nurse is responsible for the assessment of all vital signs of post-op clients. Client to receive dietary education. 1. Incorrect: This response overlooks a potentially severe problem. Moistening the dentures prior to inserting them Two nurses lifting the client under the shoulders A nurse is planning to discharge a client who has quadriplegia to his home. A family member requests that the nurse apply restraints. d. Bend at the knees when picking up an object, 99. 3. Denial Client with ureterolithiasis who requires frequent PRN pain medication. Prior to turning feeding back on, tube placement needs to be verified. 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. 1. No! This is outside the scope of practice for the LPN/LVN. 3. Which of the following actions should the nurse take? 5. 3. Increased insulin production An adolescent client post appendectomy reporting pain. d. Lean back in the chair, b. b. I will begin once the client's discharge order is written 3. a. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. 2. Incorrect: The RN is responsible for teaching. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. Feedback 4. The RN with 5 years' experience in the Labor and Delivery unit. In what order should the emergency department triage nurse send these clients to a room for treatment? 1. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) 4. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. 2. Which of the following statements by the student indicates understanding of the discussion? A nurse is performing care activities for a client in the zone of touch that requires his consent. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. A charge nurse is observing a group of newly licensed nurses. Give magnesium citrate 296 mL at 3 PM today. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. The reason for the UAP not feeding the client needs to be determined. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Right forearm Remove all metal necklaces d. Go to employee health services, b. 2. d. Determine if the client uses hearing aids, b. It is quicker to administer medications intravenously in the hospital 5. Underline the adjective clause in each sentence. 2. If a sentence is already correct, write CCC. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. c. Check to see if the suction equipment is working 1. c. Review another client's similar surgical experience Which task should the nurse take responsibility for completing? This client should report an improved respiratory, not shortness of breath. 2. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. The nurse has been assigned four clients. Stand directly in front of the client c. Request a tray without pork c. Gender A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. b. Which of the following statements should the nurse identify as an indication that the client needs further instruction? It is within the LPNs scope of practice to administer antibiotics. A client with epilepsy reporting an odd smell in the room. a. Which of the following responses should the nurse provide? Assign more daily tasks to the UAP. Tenderness over the symphysis pubis Remember, pick the killer answer first! 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. Which of the following responses should the nurse make? Have a pen and paper handy Lisinopril 20.0 mg PO daily Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. d. Water heater temp 54.4 C (130 F) d. What have you done in the past to cope with this issue? a. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). This is an appropriate and safe action for the unlicensed nursing assistant to do. The client receives home health care and spends most of his day in a reclining chair. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. 6. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. Drag and Drop the items from one box to the other. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. b. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. a. 4. Injuries from a motor-vehicle accident can be life threatening. 4. Provides day to day direction and supervision to assigned direct patient care staff. Documentation is a communication tool for the interprofessional health care team. Aplastic Anemia Support Group. The nurse prefers to check all vital signs on all clients. 2. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Triage and assign color-coded tags to each client. Place the client in a lateral position Incorrect: The nurse is responsible for evaluating a client. 6. 4. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. A client with diabetes admitted for debridement of a foot ulcer. Disconnect client's nasogastric (NG) tube suction to allow ambulation. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. b. The nurse does not know the skills of the new UAP. Only the state Board of Nursing can legally determine the LPN's scope of practice. 10. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Incorrect: This group of clients needs specific teaching. 3. Which of the following approaches should the nurse use when using confrontation? 4. a. Incorrect: The client does need to have food; however, there is another action that should be performed first. Select all that apply d. I will begin once the client's insurance company approves discharge coverage, b. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Which of the following client statements indicates an understanding of the procedure? A nurse is caring for a client who is scheduled for an elective surgical procedure. 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. Turn on local news for up-to-date information on the train derailment. d. Do you think crying will help? A nurse enters an older adult client's room to insert a saline lock. 3. a. b. Wash the area of the puncture thoroughly with soap and water 2. A nurse asks a client to share personal stories. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Obtain a client's consent c. Hand-off technique c. Offering false reassurance Which of the following actions should the nurse take? (Select all that apply) Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. Currently, your census is 11, with one empty bed. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. b. Therefore, this client would not be a priority over a client who may be experiencing a MI. Anyone over age 18 can have an Advanced directive. A nurse is developing a plan of care for a client who practices Islam. b. This should not be delegated to the LPN/LVN. Client prescribed antibiotics for cystitis. Because the charge nurse observes and weighs . 3. Incorrect: The nurse retains the responsibility for the delegated task. Removing the client's dentures Which client should be assigned to the most experienced nurse? Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Incorrect: This would unnecessarily alarm the clients. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. c. Why are you crying? A nurse is caring for a client who is postoperative following abdominal surgery. 5. 3. A client with exacerbation of COPD reporting dyspnea. Furosemide 40 mg PO q.d. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. Elderly clients have special fluid and electrolyte issues after a fall. Which of the following pieces of PPE should the nurse remove first? Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. c. When asking the client how he completes his ADLs 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. 1. Select all that apply EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. 4. A nurse is implementing direct nursing care for a group of clients in an acute care facility. 2. Battery Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. 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). Currently, your census is 11, with one empty bed. Which tasks should the charge nurse delegate to the nursing assistant? Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia.
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