A person can be designated to make medical decision in the event the client cannot. Client diagnosed with inoperative brain tumor who is confused. 3. 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. This client needs careful monitoring and specialized care. 4. 1. Which nurse should be assigned to care for this client? A client with fibromyalgia reporting generalized pain of 7 out of 10. Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. b. I'm so sorry to hear about this Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? An LPN/VN has been floated to the emergency room following a chemical plant explosion. c. Review the client's progress toward personal objectives The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. 4. Which of the following actions indicates that the AP understands the principles of infection control? Correct: Traction should never be relieved without a primary healthcare provider's prescription. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. 1. a. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. b. All these clients have a GI problem. A nurse is caring for a client who is postoperative. Moistening the dentures prior to inserting them A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. 1. a. Reposition the client every 3 hr 3. If a sentence is already correct, write CCC. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Suggest splitting the shift with another nurse. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? 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. A nurse is caring for a client who expresses anxiety about his impending surgery. 4. Select all that apply What was the hint? Obtain a urine specimen from a client with an indwelling Foley catheter. c. Holds the soiled linen against her body while carrying it to the linen bag d. Counting radial pulse c. Distended bladder Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? c. Palpating for pedal edema Which clients could be assigned to an LPN? Speak to the UAP to determine what happened with the feeding. b. I will come back later and we can talk 6. To remove gastric acid that might cause dyspepsia a. Auscultate breath should at least ever 2 hr 4. Performing passive range of motion (ROM) on the client with right sided paralysis. Which of the following tasks should the nurse delegate to AP? Ask the client to perform a return demonstration of insulin injection A nurse is caring for a client who frequently attempts to remove his IV catheter. Ask for any staff objections to rearranging work hours. d. Voided 30 mL frequently Write N next to the nonessential clauses and E next to the essential clauses. 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? e. Talking with the client's partner, 79. a. A nurse is preparing a sterile field. b. 3. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Gather supplies to prepare room for isolation. a. Feed the client after warming the food. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 2. Discuss the assignment with another LPN. Which of the following explanations should the nurse provide? e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Have another nurse finish preparing the medications Something new could have occurred with the clients, making the assignments too heavy. UAPs can assist with elimination and are taught how to measure output. 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. Which of the following is the priority action by the nurse? 3. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. 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. a. This determination is needed to assure client safety is being considered. a. 1) Bathe a client who had an amputation 2 days ago. A nurse is preparing to move a client who is only partially able to assist up in a bed. Accept assignment, documenting personal concerns regarding work conditions. Client one day post kidney transplant. What was the rationale for this plan? Ask client if they are eating small, frequent meals. b. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. The provider must renew a restraint prescription every 8 hr. d. I will begin once the client's insurance company approves discharge coverage, b. 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. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. b. A charge nurse is making assignments for an oncoming shift. A client with an above the knee amputation reporting phantom pain. Tenderness over the symphysis pubis A nurse enters an older adult client's room to insert a saline lock. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. It happened so long ago - just get over it!" Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. Anyone over age 18 can have an Advanced directive. a. Places the soiled linen in the floor before bagging it Teach the UAP to change surgical dressings. The nurse should do this when repositioning is needed. a. This is an appropriate and safe action for the unlicensed nursing assistant to do. Which of the following actions should the nurse take? 2. b. Wash the area of the puncture thoroughly with soap and water 2. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Focus on the client's present circumstances instead of his personal stories So, the UAP can assist a client to brush and floss teeth. The nurse has been assigned four clients. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Monitor client for pain while assisting with ambulation. 2. (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 5. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. The nurse received a client following surgery 8 hours ago. This referral would be appropriate. Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. 2. b. a. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. Based on these findings, to which of the following providers should the nurse request a referral for the client? 4. c. Depression 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. The LPN/LVN can reinforce teaching. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. c. I'll need to shave the hair off the skin where I place the electrodes d. They disclose more personal information, a. c. Use an aggressive tone of voice leadership management of care nurse on unit is providing care for group of clients. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. A nurse is caring for a client who has limited hand movement. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. This stage involves constructive efforts on the part of the group members b. Donation costs are the responsibility of the donor's family and estate A charge nurse is observing a group of newly licensed nurses. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. a. b. We see that the temperature is already elevated, which makes us worry that infection is present. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? 4. 4. Correct: Hot water may damage dentures so intervention is needed. 4. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. Which of the following approaches should the nurse use when using confrontation? Yes! Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Show client who has conjunctivitis how to clean the eyes. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Assist a client to ambulate using a gait belt 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. 3. An increased temperature will have a direct effect on the brain's metabolism and function. Prepare a list of clients who could quickly be discharged or transferred. b. I can detect the presence of carbon monoxide by a metallic odor d. I shouldn't advice you about what is ultimately a personal decision, b. 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. This stage is when testing occurs to identify boundaries of interpersonal behaviors There may be a good reason that the tray was not served. Remember airway, breathing and circulation (ABCs). Besides yourself, there are the following staff: Your unit has 12 beds. -Review a low-sodium diet for a client who has HTN This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. The assignment process requires constant evaluation and reevaluation of information and priorities. The surgeon initially prescribes a clear liquid diet. 8. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. d. Transporting a cerebrospinal fluid specimen to the lab Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. 1. 2. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. a. The other options may be correct but are not the best first action. Speak to the UAP first and then decide if a between meal supplement is needed. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? A nurse is providing care to a client who is on strict bed rest following surgery. a. A client with exacerbation of COPD reporting dyspnea. Incorrect. 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. Place in priority order. b. The RN with 10 years' experience pulled from the ER. There is a possibility that a hypothermia blanket may be prescribed. The client then states, "I have changed my mind and do not want to have the procedure done." Determine caregiver's stress level and coping strategies. Teaching about a medication a. 2. 4. a. Which clients should be assigned to the CNA? Offer to take one of the clients. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. 3. 2. Feed a client that had a stroke 3 months ago. 4. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. 3. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. 4. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. c. I will complete the smoking cessation program I started Sit side-by-side with the client Patient safety must remain the priority. Correct: The client who has a cast and requires pain medication is a stable and predictable client. Check environment for potential safety hazards. Client with cast to right leg requiring pain medication. In what order should the nurse assess assigned clients following shift report? Monitor for behavioral changes. 1., 2., 3., & 4. 1. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Incorrect: The nurse cannot assign teaching to the UAP. 2. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client. Aplastic anemia is a rare but serious condition. d. Move to the opposite side of the pack and open the fourth flap, 54. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. 3. The charge nurse might not have realized all the responsibilities of taking this team of clients. A client with epilepsy reporting an odd smell in the room. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. Which of the following actions is the priority for the nurse to include in the client's plan of care? Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. a. Speak using his usual tone of voice 3. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Which of the following responses should the nurse make? A nurse is teaching a client about the physical effects of chemotherapy. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. When a family member asks how respite care can help, which of the following responses should the nurse provide? Involve the client in their plan of care. 6. Refuse the assignment, being prepared for disciplinary action. Review a low-sodium diet for a client who has hypertension. c. Industry vs inferiority A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Two hours . Select all that apply b. Emptying a urinary drainage bag for a client who has pneumonia What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Point out inconsistences in the client's behavior Gather and apply dressings to open wounds. The nurse should use close-ended questions when assessing which of the following factors? The nurse also needs to be aware of the color and amount of urine voided. c. Providing anticipatory guidance to a client in crisis Monitor for GI upset 30 minutes after meals. a. 7. b. This is not a situation that requires the LPN to notify the primary healthcare provider. 4. 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. Talk to each nurse about concerns related to assigned clients. Following the teaching, the nurse asks the client to describe one physical effect. Which of the following nontherapeutic communication techniques is the nurse using? 4. - Assisting a client to ambulate using a gait belt. c. Notifying the provider of physical exam findings Estimate the number of Calories in two tablespoons of peanut Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. In option #4, we see that the leading zero is missing from the prescription. Briefly assess every client. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. Which of the following tasks should the charge nurse reassign to a licensed nurse? Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. It's unfortunate that I have to be in the hospital for this treatment Remember, pick the killer answer first! The client must understand the need for restraints 1. 1., 2., 3., & 4. 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. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. The charge nurse is making client assignments for a neuro-medical floor. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). b. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 3. C-section planning discharge, postpartum infection, mastectomy. 3. c. Leave a nightlight on in the client's room A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. d. Ambulating the client in the hallway, c. Explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on affective learning), 80. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. Incorrect: This client does not have a predictable outcome. 3. 3. Perform the Heimlich maneuver 4. a. 5. 3. 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. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Which of the following infection-control precautions should the nurse use caring for this client? 1. b. Everything will be okay Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. A nurse is prioritizing care for two clients at the start of the shift. the nurse responds, "don't worry, no one will harm your family." The women's health charge nurse is making assignments for the next shift. 2. which client would be most appropriate to assign a licensed practical nurse (lpn)? Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. d. I have a set of my brothers' crutches in the basement I can also use, a. a. The client can indicate desire for Do Not Resuscitate (DNR). Sudden attacks of sleep b. Grape juice d. Water heater temp 54.4 C (130 F) a. An Advance Directive includes a Living Will and a Medical Power of Attorney. This can prevent harm to client's. c. Washes and rinses her hands for 10 seconds, 11. d. Do you think crying will help? c. Irrigating a client's abdominal wound The nurse prefers to check all vital signs on all clients. d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. Four clients arrive for their appointment at a diabetic clinic. a. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. b. Remind the client that a signed informed consent form is a legally binding document b. Irrigate the NG tube with 100 mL of sterile water 1. 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. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Encourage client to express grief related to loss of independence. 4. Removing the abdominal dressing 3. d. Custard Select all that apply Which of the following statements should the preceptor make? Incorrect: The RN is responsible for assessment and evaluation. A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. a.) Stand directly in front of the client The nurse did not trust the new UAP. (SATA) -Bathing a client who had an amputation 2 days ago. There are a total of 10 adult clients. Incorrect: The client does need to have food; however, there is another action that should be performed first. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. b. I'll rewrap my ankle starting from the knee down 2. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. a. A client has been admitted with folic acid deficiency anemia. 5. 4. 3. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. A nurse is admitting a client from a long-term care facility. 3. 2., 3. 4. Determine which personnel could be sent to the command center. 2. 1. a. 1., 2., & 5. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? An experienced person who can research "best practice" regarding the issue is needed. Bargaining a. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. 2. A nurse is providing discharge teaching for a client who requires home oxygen therapy. 4. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. 2. 3. A nurse is caring for a client who has a mental health disorder. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. 3. The nurse suggest that the family might need to respite care services. A client requesting assistance packing his belongings for discharge later today.. b. I'll do exercises that strengthen my abdominal muscles This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The nurse cannot allow the UAP to perform advanced tasks. 5. c. Blood-tinged urine Checking capillary refill beneath the client's fingernail
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