Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Lisinopril 20.0 mg PO daily Bargaining b. Dentures should be stored in a denture cup. A client with atrial fibrillation currently on a diltiazem drip. Identify and assess each incoming client. d. I decline this opportunity at this time, b. 2. a. Schedule visiting times in two-hour increments so clients are not overwhelmed. Which client can be assigned to the LPN? Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. 4. 3. 1. Which of the following actions by the nurse is considered an indirect nursing care activity? Based on the information provided in report, which client condition should be the nurse's priority? Which of the following actions should the nurse include in the plan? What is the best first action for the nurse to take in order to achieve this goal? b. c. Holds the soiled linen against her body while carrying it to the linen bag Select all that apply. c. Decreased sodium excretion Initiate oxygen and IV lines as needed. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. d. Explain oral hygiene to a client receiving chemo A nurse wants to find out a better way to perform oral care on unresponsive clients. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. b. The client post PEG placement is stable. 1. b. I'll use the cleansing wipes from the front to back c. Distended bladder Assist a client to ambulate using a gait belt 4. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. 3. Provide positive feedback to the UAP. 4. We do not know the extent of her injuries based on what the option tells us. c. 214 Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Asking for an explanation Changing the subject Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 1. Feed the client after warming the food. Which of the following tasks should the nurse delegate to assistive personnel (AP)? b. c. Notifying the provider of physical exam findings A charge nurse is making client care assignments. Besides, a charge nurse is a leader on the floor and should possess . c. Changing a dressing, 78. The nurse should not lecture, scold or argue with the float nurse. Use adult diapers to prevent frequent clothing changes d. Counting radial pulse, 100. 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). 4. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. b. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. The charge nurse knows what client would be most appropriate for this LPN? Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Monitor for behavioral changes. Select all that apply. 5. A nurse is planning care for a female client who has an indwelling urinary catheter. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Which of the following should the nurse include as a criterion for applying restraints? A nurse is assessing a client who has narcolepsy. d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. 3. Which of the following activities should the nurse perform in this zone? There will likely be both physical and emotional injury that needs attention, which places this client third. Semi-formed stools are great news! b. A nurse is caring for a client who expresses anxiety about his impending surgery. c. We administer all medications intravenously to clients in this unit This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Which of the following instructions should the nurse include? A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. b. The nurse has received the change-of-shift report. 4. 1. c. Notify the nurse manager 2. Checking capillary refill beneath the client's fingernail Discuss the issue with the leader of the "best practices" committee. c. I'll clean the inside of the container with a wipe The client then states, "I have changed my mind and do not want to have the procedure done." The charge nurse needs additional information to make a decision. a. Perform the Heimlich maneuver I'm drinking plenty of fluids." The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Encourage the client to be more cooperative. The best practice committee utilizes current research in their recommendations. Call the family of a client suffering from dementia to discuss long term care placement. One important aspect is encouraging the flow of ideas between management and staff members. 3. b. 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. b. Donation costs are the responsibility of the donor's family and estate (Select all that apply.). Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? d. Social conversation, a. Incorrect: This would unnecessarily alarm the clients. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. Which of the following statements should the nurse identify as an indication the client needs further teaching? 2. Alert all off-duty personnel to stand by in case of call- in. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. A high concentration of carbon monoxide can cause death 1. & 5. b. I'm so sorry to hear about this Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? Notify the primary healthcare provider of transfer completion. c. I will begin upon the client's admission to the facility b. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. b. 3. A list of current medications is sent to the facility. 2. Confrontation should occur in the presence of a charge nurse or supervisor. d. Place the tablet directly into a medication cup, 36. A nurse just back from maternity leave. Explore the client's feelings Incorrect: This is not completely practical for everyone. c. Initiate a liquid diet for the client This referral would be appropriate. 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. When a family member asks how respite care can help, which of the following responses should the nurse provide? Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. When the licensed person cannot determine this, the task should not be delegated. A family member requests that the nurse apply restraints. Which of the following actions is the priority for the nurse to include in the client's plan of care? Incorrect: The RN is responsible for collecting data. Which prescription should the nurse question and have corrected? d. Lean back in the chair, b. b. A client receiving heparin injections for deep vein thrombosis. 2. Decreased RBC production Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Gown 3. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Offer to take one of the clients. 4. A nurse instructs a female client about collecting a midstream urine sample. Handoff and Nursing Report Sheet. d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. Request a prescription for a medication to ease the client's anxiety d. Complete an incident report, 70. 1) Bathe a client who had an amputation 2 days ago. Which action should the nurse interrupt the UAP from performing? a. d. Water heater temp 54.4 C (130 F) a. 1. Decide which choice fits best in the blank. Pain Female client stating she has been raped. 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. Disconnect client's nasogastric (NG) tube suction to allow ambulation. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. b. I will try to anticipate and avoid stressful situations when possible Speak to the UAP to determine what happened with the feeding. 1. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. b. 4. Explain to the RN that all the nurses have the same number of clients. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Which region of the tRNA pairs with mRNA? Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. b. The report should contain consequences. 3. 4. 3. c. Face shield The nurse received a client following surgery 8 hours ago. a. I will begin 48 hr before the client's discharge Collecting I & O totals for unit clients at the end of shift. Plan all care to be completed in early morning to allow afternoon for visitation. One nurse lifting as the client pushes with his feet 3. Placing the traction weights on the bed to transfer the client to x-ray. 2. b. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Which of the following infection-control precautions should the nurse use caring for this client? 4. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. 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. Notify the nursing supervisor of the situation. 4. Electric cords behind the furnitrure 6. c. Explore the client's feelings about dietary modifications There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. The client is reporting anxiety, discomfort, and a feeling of bloating. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. Besides yourself, there are the following staff: Your unit has 12 beds. c. Explain the risks and benefits of the procedure Assist a client to ambulate using a gait belt b. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. The nurse asks why the client needs to know this. 3. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. c. Rephrase statements the client does not hear Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). The reason for the UAP not feeding the client needs to be determined. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. The surgeon initially prescribes a clear liquid diet. The nurse has been assigned four clients. 1. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. Which of the following actions should the nurse take regarding informed consent? Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? 6. 1. The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. To focus on effective learning with this client, which of the following interventions should the nurse use? This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Both of these clients are terminal. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. d. Providing information, a. 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. b. Wash the tablet off with alcohol and place it in a clean medicine cup 3. "The client is weak on the right side, so please assist the client with dressing . Each ROM movement should be repeated 5 times during the session. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Notify clients that the disaster plan has been put into effect. c. Discard any residual gastric contents Currently, your census is 11, with one empty bed. Which of the following actions is an example of a violation of confidentiality? Which client should be assigned to the most experienced nurse? Simply accept the assignment since overtime is mandatory. Incorrect: The RN is responsible for assessment and evaluation. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Client scheduled for breast reconstruction after mastectomy. leadership management of care nurse on unit is providing care for group of clients. Teaching about a medication A medical-surgical LPN has been sent to a short-staffed pediatric unit. Drag and Drop the items from one box to the other. 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. It happened so long ago - just get over it!" 3. 4. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. The abdominal pain is worsening. a. Hypotension Evaluate client's safety risk factors. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Which of the following responses should the nurse make? Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47. c. Why are you crying? A nurse is caring for an older client who is at risk for skin breakdown. Perform range of motion (ROM) exercises at least 2-3 times daily Select all that apply. Stand directly in front of the client IV of D5 NS at 75 mL/hour with a 20 gauge catheter. Talk to each nurse about concerns related to assigned clients. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. The nurse would then start the 24 hour urine once the 1st void has been discarded. b. I will come back later and we can talk 5. What is the best response by the charge nurse? b. eminent Providing hygiene care to a client who is HIV positive d. Perception 4. Allow families unlimited visitation around the clock to meet their schedules. Select all that apply Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. What was the hint? A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). 2. C-section planning discharge, postpartum infection, mastectomy. 3. 3. Nothing by mouth (NPO). c. Palpating for pedal edema 5. 1., 2., & 5. a. 1. Did you think dehydration and fluid volume deficit? This task cannot be delegated to the LPN/LVN. and 16 g of fat. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures The nurse is using which level of communication at this time? c. Offer the client personal thoughts and beliefs Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Place the pack on a sterile work surface b. Massage any bony prominences to promote circulation 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. c. I should purchase a carbon monoxide detector for my home Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. Respite care provides holistic support and care for a client who is terminally ill (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. The client states, "I'm feeling a bit nervous today." The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. Because the charge nurse observes and weighs . 4. 2. d. Left forearm, b. 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. d. Droplet, d. Bend at the knees when picking up an object, 98. Autonomy vs shame and doubt 3. Client one day post kidney transplant. 4. 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. 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 c. I'll wear low heeled shoes from now on d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. 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.
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