Aplastic anemia is a rare but serious condition. 1. Which of the following statements should the nurse make? Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. 1. Tenderness over the symphysis pubis A client with diabetes admitted for debridement of a foot ulcer. b. Once the client is stable, the UAP could perform this task. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. A nurse asks a client how he is feeling. c. Use intermittent eye contact c. I'll clean the inside of the container with a wipe 3. butter, which contain 16 g of protein, 7 g of carbohydrates, d. Custard Did you think dehydration and fluid volume deficit? a. 1. 2) Assist a client to ambulate using a gait belt. Education d. Services are centered in long-term care facilities, a. Which of the following actions should the nurse perform when opening the sterile pack? The nurse should assess the client for which of the following expected outcomes after catheter removal? Patient safety must remain the priority. 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. Incorrect: Medications are not transferred with the client to a new facility. 5. Dexlansoprazole 30 mg PO daily. Drag and Drop the items from one box to the other. 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. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. B. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. a. A lack of rapid eye movement (REM) sleep a. which client would be most appropriate to assign a licensed practical nurse (lpn)? 4. b. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Hanging a new bag of total parenteral nutrition (TPN). 2. 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. Which clients could be assigned to an LPN? Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. is a new graduate in orientation. 4. 2. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Provide positive feedback to the UAP. 4. d. They disclose more personal information, a. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. 4. 1., 2., 3., & 4. This client is at a high risk of infection. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? Protective a. I'll apply ankle to my ankle today and tomorrow Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. Discuss the competency of the surgeon C-section planning discharge, postpartum infection, mastectomy. Performing passive range of motion (ROM) on the client with right sided paralysis. c. Industry vs inferiority EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Select all that apply. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Take several shallow breaths during the procedure Empty the drainage bag at least every 8 hrb.) c. Offering false reassurance Client with a T-5 spinal cord injury beginning rehabilitation therapy. 1. b. Urinary frequency for several days Perform catheterization when you recognize the urge to void Which of the following is the priority action by the nurse? Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. Which of the following statements should the nurse make? c. I'll bear weight on my ankle for 10 minutes every hour Battery I'm drinking plenty of fluids." The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Which of the following actions should the nurse take? So, the UAP can assist a client to brush and floss teeth. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Encourage the client to be more cooperative. 1. Select all that apply It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. So, now you must decide which of these high priority clients should be seen in what order. What should the nurse do first? A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. There is a trailing zero after the prescribed dose. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. 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. Dentures should be stored in a denture cup. They are able to manage tasks related to basic care. 3. A nurse enters an older adult client's room to insert a saline lock. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. A high concentration of carbon monoxide can cause death 4. 3. Providing a passive response Obtain a urine specimen from a client with an indwelling Foley catheter. Photo comes from the Greek word for light. Assigning blame for the changes to administration will not help staff adjust. 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. 1. b. I'll rewrap my ankle starting from the knee down Which of the following client statements indicates an understanding of the procedure? 1. A client with a fractured right humerus who reports the cast is too tight. Electric cords behind the furnitrure The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. b. I'll use the cleansing wipes from the front to back It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. Client with cast to right leg requiring pain medication. A nurse is completing discharge teaching with a client. Donning gloves and using a gauze pad to grasp and remove dentures Which client can be assigned to the LPN? _________________ (magnanimous), a. generous Notify the nursing supervisor of the situation. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Notify the charge nurse of the observations. d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. The first vital sign check was performed by the nurse. c. Check to see if the suction equipment is working Witness the client's signature The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. 2. Denial What action should the nurse take after mistakenly administering the wrong medication? 2. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? Decreased RBC production b. 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. This service began with the client's admission to the hospital 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. Where on the body is each type of skin found? Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Request a prescription for a medication to ease the client's anxiety c. Washes and rinses her hands for 10 seconds, 11. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Which of the following actions should the nurse take to assist the client with feeding? Notify clients that the disaster plan has been put into effect. b. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. There is a possibility that a hypothermia blanket may be prescribed. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Provide a between meal supplement to the client. 3. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. The LPN can monitor the wound and provide care to the PEG insertion site. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. Incorrect: The nurse is responsible for monitoring a client. They are likely to wait for others to initiate conversation Teaching about a medication Correct: The client has the right to be involved in the decision making of their care. A nurse is caring for a client in the orientation phase of the nurse-client relationship. d. principal. Cardiac catheterization with a decreased pedal pulse below insertion site. 3. Administering 3 g/hr IV of morphine would be extremely dangerous. Currently, your census is 11, with one empty bed. Convenience for the nursing staff or the client's family c. Rephrase statements the client does not hear Select all that apply Transfer essential medical record to the receiving facility. Which of the following actions should the nurse take? Could you try contacting a support group This includes medication enemas. Place in priority order. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. 5. It is quicker to administer medications intravenously in the hospital Select all that apply 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. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. a. Incorrect: Informing is the same thing as teaching. A client has been admitted with folic acid deficiency anemia. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 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. d. Go to employee health services, b. c. Gender 3. The LPN should refuse the intervention. Occupational therapist 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. 2. When the licensed person cannot determine this, the task should not be delegated. d. Mask, 83. b. D. c. Nonfat milk During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 1. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) Remind the client to tell the nurse when he has to urinate a. Reposition the client every 3 hr 2. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. 3. Assist a client to ambulate using a gait belt The reason for the UAP not feeding the client needs to be determined. a. Have another nurse finish preparing the medications Anyone over age 18 can have an Advanced directive. 2. 3. b. I will keep the fluorescent ceiling light on in my room at night Initiative vs guilt The nurse could definitely be part of the committee. What was the rationale for this plan? A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. 4. But the client does need to be assessed prior to the client with Crohn's disease who is improving. A charge nurse is making assignments for an oncoming shift. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. 6. However, it remains true pain for this client and the client would need intervention to help manage this pain. Correct. 4. Nothing life threatening. Make nursing assignments appropriate to the skill level . 3. c. Discard the tablet and obtain another dose of medication Decide which choice fits best in the blank. The nurse caring for the client at the time of death requests organ donation TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Phone report to the receiving nurse. When a family member asks how respite care can help, which of the following responses should the nurse provide? Incorrect: This would unnecessarily alarm the clients. a. d. Lean back in the chair, b. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department b. d. Water heater temp 54.4 C (130 F) Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? Gathering needed equipment and supplies is within the scope of duties for the UAP. d. Motor impairment, 84. Which of the following actions should the nurse take? A charge nurse is making client care assignments. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. 9. Which client should the nurse see first? Alcoholic Anonymous Place in priority order. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? d. I will place a bath seat in my shower to use when I bathe, b. The client is considered unstable until assessed by the nurse. The charge nurse on the postpartum unit is making assignments. Inform the client of the need to avoid irritants such as carbonated beverages. Drag and Drop the items from one box to the other. In option #4, we see that the leading zero is missing from the prescription. Explore the client's feelings This service began with the client's admission to the hospital, 18. 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. d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. What options would be appropriate for the nurse to take? 6. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 1. 1. Discuss the issue with the leader of the "best practices" committee. 4. d. Place the tablet directly into a medication cup, 36. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". 2. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. A nurse is caring for a client who is scheduled for an elective surgical procedure. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Handoff and Nursing Report Sheet. d. Message, 67. Which of the following methods should the nurse plan to use? Call the client's provider Assessing this client and titrating the diltiazem requires the skills of an RN. 4. Incorrect: Moistening the dentures will ease insertion. The client asks the nurse, "Why do I need that? What would the approximate meaning of photoelectric be, based on these root words? 2. b. 4. The RN with 2 weeks' experience on the postpartum unit. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. c. Depression Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Which of the following info should the nurse include? The RN with 8 years' experience in the Intensive Care Unit. 1., 4., & 5. Provides day to day direction and supervision to assigneddirect patient care staff . The primary healthcare provider may have suggestions but this is not the best first action. Gather and apply dressings to open wounds. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which action by an unlicensed nursing assistant would require the nurse to intervene? The client says, "go away, no one can help me." b. 3. Elderly clients have special fluid and electrolyte issues after a fall. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Receive report from the emergency department (ED) on a new client. However, there are some basic points which are standard among all facilities. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Notify the surgeon that the client wishes to withdraw informed consent for the procedure The surgeon initially prescribes a clear liquid diet. 3. Select all that apply Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. The best practice committee works to improve clinical practice based on current research. Nothing will get passed the complete blockage. A client receiving a blood transfusion that requires monitoring. Which task should the nurse take responsibility for completing? 4. Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. 3. The nurse is reviewing some clients' prescriptions. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? b. 1. 4. Which of the following statements should the nurse identify as an indication that the client needs further teaching? What task would be best to assign to the LPN/LVN? This is the most stable of the four clients which places this client last to be seen. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. What task would be best to assign to the LPN/LVN? 3. 1. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. (Select all that apply.). 1 Two nurses lifting the client under the shoulders b. 4. The nurse would then start the 24 hour urine once the 1st void has been discarded. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 3. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. & 3. Showing disapproval The client is apparently stable and does not require any advanced assessment skills or specialized care. A client with fibromyalgia reporting generalized pain of 7 out of 10. There are a total of 10 adult clients. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Which of the following should the nurse include as a criterion for applying restraints? The expected standard of care was strict bed rest), 96. b. Irrigate the NG tube with 100 mL of sterile water a. Encourage the client to use self-exploration Licenced practical nurses are a little less educated than registered nurses. a. Ask client if they are eating small, frequent meals. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. Select all that apply Which of the following actions should the nurse take? Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. Clients over the age of 65 must have a saline lock according to facility policy 4. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. c. Discard any residual gastric contents It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. A nurse is providing care to a client who is on strict bed rest following surgery. 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. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. 1., 2., 4., & 5. The nurse is using which level of communication at this time? The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift.
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