c. The restraints should promote the client's safety and prevent injuries Fruity breath. Pain b. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. & 5. a. Incorrect: What seems to be going on with this client? 4. 4. Evaluate client's safety risk factors. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? The cause of the fall may be cardiac, but the question does not indicate this. 4. Feed a client that had a stroke 3 months ago. The client's self-report of pain severity Select all that apply. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. a. 4. The nurse considers various ideas submitted by team members. leadership management of care nurse on unit is providing care for group of clients. The LPN/LVN can reinforce teaching. Correct: The client has the right to be involved in the decision making of their care. c. Hand-off technique Collecting I & O totals for unit clients at the end of shift. The client asks about his medications and their effects. Talk to each nurse about concerns related to assigned clients. a. 1. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. 4. 2. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. A client with diabetes admitted for debridement of a foot ulcer. The nurse is caring for four clients. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. d. Social conversation, a. The nurse voices his concern to the charge nurse. Also, making a surgical bed for the client returning from surgery is a basic procedure. Which of the following items should the nurse include on the lunch tray? Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The primary healthcare provider may have suggestions but this is not the best first action. Charge nurses have integral roles in healthcare organizations. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. a. This determination is needed to assure client safety is being considered. 2. d. Determine if the client uses hearing aids, b. 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. Measure urine output when client voids. Nothing will get passed the complete blockage. What was the rationale for this plan? Correct: The client may be experiencing a myocardial infarction and requires further assessment. Accept the client's behavior as confrontational. Client reporting epigastric pain and nausea after eating. Which of the following methods should the nurse plan to use? Stand directly in front of the client 4. The charge nurse knows what client would be most appropriate for this LPN? Select all that apply a. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. 1. 2. e. Feed a client who had a stroke 3 months ago, 31. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. a. 4. a. c. Changing a dressing The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. 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 is about to have a colonoscopy. 4. A list of current medications is sent to the facility. & 6. Drag and Drop the items from one box to the other. 4. Which of the following actions is the priority for the nurse to include in the client's plan of care? D. the nurse responds, "don't worry, no one will harm your family." b. Emptying a urinary drainage bag for a client who has pneumonia A charge nurse is making assignments for an oncoming shift. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. 212 A nurse wants to find out a better way to perform oral care on unresponsive clients. Tenderness over the symphysis pubis c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). Obtain a bedside commode for the client's use c. Irrigating a client's abdominal wound 2. b. Wash the tablet off with alcohol and place it in a clean medicine cup Although this will require assessment, this client is not the priority at this time. 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. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. Correct: Hot water may damage dentures so intervention is needed. A nurse is caring for a client who has a wound infection. b. Irrigate the NG tube with 100 mL of sterile water d. I will begin once the client's insurance company approves discharge coverage, b. b. Urinary frequency for several days This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. b. A client with fibromyalgia reporting generalized pain of 7 out of 10. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. 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. 4. a. Clarifying b. A nurse is caring for an older client who is at risk for skin breakdown. 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. (Select all that apply.). Show client who has conjunctivitis how to clean the eyes. a charge nurse is making client care assignments for the day. c. Physical therapist Protective _____The house that we lived in for nine years has been sold. d. Remove tea and coffee from meal trays, b. 2. Of my three brothers and sisters, my sister Giselle has the best sense of humor. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. The nurse is using which level of communication at this time? c. Lock the medication in a room and finish preparing it after returning from the emergency A nurse receives a client care assignment from the charge nurse that he believes is unfair. A nurse caring for a client is using active listening skills. Client with cast to right leg requiring pain medication. Use the tablet's packaging to pick it up from the counter Which nursing intervention should the charge nurse implement? 1. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Give magnesium citrate 296 mL at 3 PM today. Incorrect: This client is exhibiting early signs of increased intracranial pressure. c. Use intermittent eye contact Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Which of the following actions should the nurse take first? Nurses dependent on drugs or alcohol can harm clients. c. Paraphrasing Warm the feeding solution to the body temperature Make nursing assignments appropriate to the skill level . Right forearm c. One nurse lifting the client's legs as the client uses a trapeze bar A charge nurse is making client care assignments. Clients over the age of 65 must have a saline lock according to facility policy 4. 5. The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. a. 5. c. Notifying the provider of physical exam findings A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 4. Only a plain enema or soap enema can be given by the UAP. c. Industry vs inferiority Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 3. It is not a routine task. Client with a T-5 spinal cord injury beginning rehabilitation therapy. Incorrect: The RN is responsible for assessment and evaluation of clients. c. I will complete the smoking cessation program I started Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. a.) The nurse should assess the client for which of the following expected outcomes after catheter removal? A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Place the client in low Fowler's position This should not be delegated to the LPN/LVN. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This could indicate a worsening of this client's condition. c. Include intact skin at the wound edges in the culture 3. The nurse is reviewing some clients' prescriptions. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Receive report from the emergency department (ED) on a new client. Estimate the number of Calories in two tablespoons of peanut 1., 3, & 4. One nurse lifting as the client pushes with his feet The nurse chooses to confront the client. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. 2. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. b. I'll do exercises that strengthen my abdominal muscles Correct: An LPN should be assigned clients with predictable outcomes. Provide an adaptive feeding device for the client, 50. 1. The option does not say the client is terminal, in a vegetative state, or in a coma. Report of feeling pressure Remind the client to tell the nurse when he has to urinate Who should the nurse see first? c. Depression So, the UAP can assist a client to brush and floss teeth. The nurse is using which of the following therapeutic communication techniques? Triage and assign color-coded tags to each client. 2. The third client that should be sent back for treatment is the female client stating she has been raped. 1. b. Serve food that have a hot/cold balance 2. d. Highly concentrated urine, 91. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. c. The emphasis is on the client's complete recovery from the illness or injury Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Client with chronic emphysema experiencing mild shortness of breath. a. a. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Provides day to day direction and supervision to assigneddirect patient care staff . 1. Involve the client in their plan of care. 3. Which of the following actions should the nurse include in the plan? Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Which of the following actions should the nurse take? Client diagnosed with inoperative brain tumor who is confused. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Nothing life threatening, but an assessment needs to be made regarding the ulcer. Explore the client's feelings 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. Risperidone .5 mg PO daily Where on the body is each type of skin found? 3. What should the nurse do first? 3. Which of the following RNs should not be assigned to this baby? Provide a between meal supplement to the client. So what is wrong with option #1? Currently, your census is 11, with one empty bed. 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. a. 3. A nurse who is on hormone replacement therapy. Feed the client after warming the food. A nurse enters an older adult client's room to insert a saline lock. Documentation is a communication tool for the interprofessional health care team. a. Which of the following activities should the nurse perform in this zone? Did you recognize ureterolithiasis as "kidney stones"? 4. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Encourage client to express grief related to loss of independence. This client is at a high risk of infection. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. 3. a. Hypotension They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. 1. 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. 3. Each ROM movement should be repeated 5 times during the session. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. a. This is an appropriate prescription. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. c. Complete an incident report Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. Provides day to day direction and supervision to assigned direct patient care staff. Which of the following tasks should the nurse delegate to assistive personnel (AP)? The nurse should perform which of the following activities in this space? The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Which of the following statements should the preceptor make? Client with ureterolithiasis who requires frequent PRN pain medication. There are a total of 10 adult clients. The LPN should refuse the intervention. The client post PEG placement is stable. a. 3. Incorrect: The nurse is responsible for evaluating a client. This is a task that can be delegated to the LPN/LVN. A nurse is caring for a client who is scheduled for an elective surgical procedure. Aplastic anemia is a rare but serious condition. d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. 1. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. 4. 3. c. Review another client's similar surgical experience a. Teaching about a medication c. I will cover the catheter so he cannot see it Which of the following actions is an example of a violation of confidentiality? A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. In option #4, we see that the leading zero is missing from the prescription. Which of the following infection-control precautions should the nurse use caring for this client? Which of the following actions should the nurse take? Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. A nurse is filling out an incident report after finding a client lying on the floor. 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. The client can indicate desire for Do Not Resuscitate (DNR). Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? b. Obtain a urine specimen from a client with an indwelling Foley catheter. d. What have you done in the past to cope with this issue? Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Ask the charge nurse to evaluate the intervention. a. b. The stem does not indicate any loss of neurological function resulting from the seizure activity. Which of the following responses should the nurse provide? Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? a. Bathtub with rails 4. A cardiac step down unit has requested float staff because of multiple impending admissions. Correct: This group of clients is primarily med surgical. Which of the following client statements indicates an understanding of the procedure? Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. Currently, your census is 11, with one empty bed. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. This is an appropriate and safe action for the unlicensed nursing assistant to do. 4. Incorrect: Informing is the same thing as teaching. 5. a. Broth Dexlansoprazole 30 mg PO daily. 2. a. Speak to the UAP first and then decide if a between meal supplement is needed. 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. Which action should the nurse interrupt the UAP from performing? The client is reporting anxiety, discomfort, and a feeling of bloating. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. Four clients arrive for their appointment at a diabetic clinic. What is the best first action for the nurse to take in order to achieve this goal? 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. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 1. a. Ask for any staff objections to rearranging work hours. Following a large hurricane, multiple clients arrive at the emergency room for treatment. a. d. Counting radial pulse, 100. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Two nurses lifting the client under the shoulders Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. c. I'll clean the inside of the container with a wipe The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. Which client should the nurse see first? Accept assignment, documenting personal concerns regarding work conditions. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. 1. d. Identifying the client by name when making a referral for home health services, 30. _________________ (magnanimous), a. generous Which of the following actions should the nurse take? 3. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. 5. d. Perception 1. and 16 g of fat. However, providing care for missing teeth would also be within the LPN scope of practice. Which of the following statements by the student indicates understanding of the discussion? A nurse is caring for a client who has limited hand movement. Female client stating she has been raped. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. 2. Wears a gown when entering the room of a client who requires contact precautions 4. Discuss the competency of the surgeon 3. 2. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. 3. 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. b. I'm so sorry to hear about this Sudden attacks of sleep Which clients should be assigned to the CNA? Removing the abdominal dressing a. I'll urinate a little then stop A nurse is admitting a client from a long-term care facility. When the licensed person cannot determine this, the task should not be delegated. 2. 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. Pick up the tray and tell the UAP that they didn't do a good job. It's just not the right time for me to do this b. Select all that apply A nurse just back from maternity leave. Incorrect: Medications are not transferred with the client to a new facility. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. c. Why are you crying? When a family member asks how respite care can help, which of the following responses should the nurse provide? A charge nurse is observing a group of newly licensed nurses. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 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. Have a pen and paper handy d. Services are centered in long-term care facilities, a. butter, which contain 16 g of protein, 7 g of carbohydrates, 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. The healthcare team should recognize the client as the center of the team. Try different methods of oral care on unresponsive clients to see what works best. e. Suctioning a client's new tracheostomy tube, 93. 4. 5. Administering 3 g/hr IV of morphine would be extremely dangerous. d. Voided 30 mL frequently b. Encourage the client to use self-exploration The best practice committee works to improve clinical practice based on current research. 3. 3. c. Review the client's progress toward personal objectives Which of the following actions should the nurse take? Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 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. The nurse caring for the client at the time of death requests organ donation 2. 2. 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. Incorrect: The nurse cannot assign teaching to the UAP. Well, do you see the q.d.? Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 3. b. Negligence 10. Incorrect: Moistening the dentures will ease insertion. Determine caregiver's stress level and coping strategies. 2. 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. Place the pack on a sterile work surface Notify the primary healthcare provider of transfer completion. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 4. What would the approximate meaning of photoelectric be, based on these root words? d. Go to employee health services, b. However, there are some basic points which are standard among all facilities. The nurse should initiate a referral with which of the following members of the interprofessional health care team? This would be an acceptable task to assign to the UAP. 2. 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. b. I will keep the fluorescent ceiling light on in my room at night 1. Which of the following actions should the nurse take prior to administering the tube feeding? a. Temporary urinary retention 2. 2. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. Speak to the UAP to determine what happened with the feeding. One important aspect is encouraging the flow of ideas between management and staff members. 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. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. This stage involves constructive efforts on the part of the group members Hanging a new bag of total parenteral nutrition (TPN). b. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. Provides safe, effective delivery of patient care in . Which of the following findings should the nurse identify as a safety risk? A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Changing the subject Autonomy vs shame and doubt Discuss the issue with the leader of the "best practices" committee. A nurse is completing discharge teaching with a client. Teach caregivers memory enhancement aids. 4., & 5. The client with chronic emphysema has expected shortness of breath. 3. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). 3. This is likely cholelithiasis, which will need to be checked out. Observe the client before taking further actions A client requesting assistance packing his belongings for discharge later today., Occupational therapist Place in priority order. 5. A family member requests that the nurse apply restraints. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. nudy's cafe nutritional information, italian chef who died recently, pentagon employee directory,
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