1. This client should report an improved respiratory, not shortness of breath. b. 1. Which of the following statements should the nurse make? Once the client is stable, the UAP could perform this task. c. Request a tray without pork Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? Speak using his usual tone of voice 1., 4., & 5. 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. 4. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Clients over the age of 65 must have a saline lock according to facility policy Correct: The unlicensed nursing assistant should not turn tube feedings off or on. 4. Checking capillary refill beneath the client's fingernail 3. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" d. What have you done in the past to cope with this issue? 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. 2. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. A client has been admitted with folic acid deficiency anemia. Pick up the tray and tell the UAP that they didn't do a good job. This includes medication enemas. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. M2.4 Making Client Care Assignments - GECC As the RN charge nurse, you are preparing to make assignments for the oncoming shift on the medical-surgical unit. 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. The nurse should perform which of the following activities in this space? d. They disclose more personal information, a. Electric cords behind the furnitrure c. 214 A client diagnosed with rheumatoid arthritis needing discharge teaching. The client asks about his medications and their effects. Client reporting epigastric pain and nausea after eating. 5. a. b. Negligence The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. c. Foot 2. 3. 1. 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). a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Assessing this client and titrating the diltiazem requires the skills of an RN. A charge nurse is making client care assignments. Obtain a bedside commode for the client's use 2. 4. b. a. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Perform the Heimlich maneuver 3. Involve the client in their plan of care. Based on this information,what should the nurse do? 4. 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. This is a diabetic clinic. 3. c. Depression The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. A nurse is planning care for a female client who has an indwelling urinary catheter. b. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. 3. 2. All these clients have a GI problem. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). a. A client with COPD complaining of shortness of breath on exertion. a. Gather and apply dressings to open wounds. Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding). 2. 1. 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. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. d. Highly concentrated urine, 91. 3. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. Following the teaching, the nurse asks the client to describe one physical effect. Review the action of insulin therapy 2. e. Feed a client who had a stroke 3 months ago, 32. D. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. 2. What was the hint? A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. It's just not the right time for me to do this 6. a. Reposition the client every 3 hr They are able to manage tasks related to basic care. b. c. Raised toilet seats Changing a colostomy bag. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Determining the client's length of stay Use the tablet's packaging to pick it up from the counter c. Washes and rinses her hands for 10 seconds c. Notify the nurse manager Explain to the RN that all the nurses have the same number of clients. Based on these findings, to which of the following providers should the nurse request a referral for the client? 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. 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. c. Discard any residual gastric contents Documentation of what occurred, and the client's assessment is required in the nurse's notes. a. 3. 5. The first vital sign check was performed by the nurse. Could you try contacting a support group 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. a. Place the client in low Fowler's position 1. d. Transporting a cerebrospinal fluid specimen to the lab When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Notify the surgeon that the client wishes to withdraw informed consent for the procedure This schedule may leave some clients too exhausted to visit with family. Removing the client's dentures Notify the primary healthcare provider of transfer completion. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. 4. Which of the following actions should the nurse take? Include any relevant statements the client made about the ulcer, 64. This protein is released by cells in the stomach. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. Select all that apply. d. The nurse has already considered alternatives to restraints, a. 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. 5. Which of the following instructions should the nurse include? 2. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. This client needs ongoing monitoring which is within the scope of practice for the LPN. a. Bathe a client who had an amputation 2 days ago d. Social conversation, a. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) 1. 3. Tenderness over the symphysis pubis The nurse should call for immediate help so that a safe care environment is maintained for all clients. 2. 3. A nurse is creating a discharge plan. The area surrounding the insertion site feels warm to the touch d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. 4. So, now you must decide which of these high priority clients should be seen in what order. Protective 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). A nurse asks a client how he is feeling. Which of the following of Erikson's developmental stages should the nurse consider in the planning? Draining the colostomy bag on a client with diarrhea. The client can indicate desire for Do Not Resuscitate (DNR). As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. 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. This action is a defensive intervention, and does not address the quarrelsome behavior. This should not be delegated to the LPN/LVN. Ask for any staff objections to rearranging work hours. 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 has a new diagnosis of type 1 diabetes mellitus. e. The urge to move the legs when trying to sleep, 66. Female client stating she has been raped. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Empty the drainage bag at least every 8 hrb.) Correct: The medical nurse can be assigned to this client. Select all that apply Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. a. Gloves 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. Therefore, this would not be the most appropriate nurse to assign to this client. b. Which of the following indications should the nurse include? a. The client is apparently stable and does not require any advanced assessment skills or specialized care. 4. a. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. . Client with ureterolithiasis who requires frequent PRN pain medication. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures Assist a client to ambulate using a gait belt It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). The client was lying on the floor next to his bed 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. Nursing questions and answers. Briefly assess every client. & 3. 2. Assist ait to ambulate using a gait belt. 4. The RN with 5 years' experience in the Labor and Delivery unit. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). For which of the following tasks should the nurse wear protective eye equipment. _____The house that we lived in for nine years has been sold. c. I will begin upon the client's admission to the facility Client with cast to right leg requiring pain medication. Incorrect: The concern here is the client being fed their meal. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. 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). 2. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. Nothing life threatening. This service began with the client's admission to the hospital, 18. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. Which of the following actions is the priority for the nurse to include in the client's plan of care? Which of the following should the nurse identify as an interpersonal variable? Underline the adjective clause in each sentence. Administer tap water enemas until clear at 6 AM. Select all that apply. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Place in priority order. To which of the following rooms should the nurse assign the client? Which action should the nurse interrupt the UAP from performing? b. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. 6. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. 4. So, the UAP can assist a client to brush and floss teeth. A nurse is caring for a client who is immobile. b. Donation costs are the responsibility of the donor's family and estate What options would be appropriate for the nurse to take? 1. Confrontation should occur in the presence of a charge nurse or supervisor. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. *HURST REVIEW Qbank/Customize Quiz - Manageme, *HURST REVIEW Qbank/Customize Quiz - Adult He, *HURST REVIEW Qbank/Customize Quiz - Basic Ca, *HURST REVIEW Qbank/Customize Quiz - Fundamen, ***HURST REVIEW NCLEX-RN Readiness Exam 1***, The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Edge Reading, Writing and Language: Level C, David W. Moore, Deborah Short, Michael W. Smith. 1. d. Message, 67. (Select all that apply.) To confirm the placement of the NG tube A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. A nurse is admitting a client who has a partial hearing loss. 3. The nurse received a client following surgery 8 hours ago. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. Reach around the pack and open the top flap away from the body, 53. b. Select all that apply leadership management of care nurse on unit is providing care for group of clients. Encourage clients and families to develop mutually appropriate visitation times. Which actions should be instituted by each unit's charge nurse? 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. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. c. Physical therapist Correct: Traction should never be relieved without a primary healthcare provider's prescription. 4. Removing the abdominal dressing Invite staff to contribute ideas on scheduling changes. Notify the primary healthcare provider. d. Let's wait until tonight to see if he continues his behavior, 63. A nurse is discussing the norming stage of the group development process with a student nurse.
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