3. During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate? A client post pacemaker insertion, awaiting discharge instructions. 4. Everything will be okay The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Initiate oxygen and IV lines as needed. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. 1. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. This is the most stable of the four clients which places this client last to be seen. b. Notify the primary healthcare provider. Incorrect: The nurse cannot assign teaching to the UAP. 3. (Select all that apply.). A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 5. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. What is the major histological difference between thick and thin skin? c. Tie linen bags securely at the top Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Schedule visiting times in two-hour increments so clients are not overwhelmed. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? Select all that apply. This is an elderly client who is a new admit. a. 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. d. Left forearm, b. c. One nurse lifting the client's legs as the client uses a trapeze bar Which of the following client statements should indicate to the nurse the need for additional teaching? b. 5. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. Risperidone .5 mg PO daily It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. a. He charge nurse is making client care assignments for the evening shift. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Select all that apply b. 2. A nurse is implementing direct nursing care for a group of clients in an acute care facility. c. Irrigating a client's abdominal wound A client with fibromyalgia reporting generalized pain of 7 out of 10. Denial A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. a. I'll urinate a little then stop So what is wrong with option #1? 4. d. Mask, 83. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. d. Reduced blood viscosity, a. Auscultating heart sounds d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. 4. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. A nurse is prioritizing care for two clients at the start of the shift. b. }? benefactor of the world. Therefore, this client would not be a priority over a client who may be experiencing a MI. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? a. b. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. 2. Place in priority order. What is the primary factor for the charge nurse to consider when delegating care? 2. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. What action should the nurse implement first to ensure client safety? Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. A nurse is preparing to obtain a blood specimen from a client by venipuncture. December 5, 2020. The nurse is planning care for a client admitted with Alzheimer's Disease. Administer tap water enemas until clear at 6 AM. A goal for this client is to use proper body mechanics at all times. 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. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? 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. Refuse the overtime assignment, being prepared for disciplinary action. Select all that apply. 6. 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. 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. What action should the nurse take after mistakenly administering the wrong medication? b. c. Respite care helps relieve pain and promote comfort 4. 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. Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. b. Irrigate the wound with an antiseptic prior to obtaining the specimen 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. 1) Bathe a client who had an amputation 2 days ago. Delegate 2 nurses to work with the client. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Incorrect: The RN is responsible for assessment and evaluation. Teach caregivers memory enhancement aids. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. A nurse is caring for a client whose partner asks to speak with the nurse. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? c. Nonfat milk The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Temporary urinary retention Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 1. A client with epilepsy reporting an odd smell in the room. This stage is when testing occurs to identify boundaries of interpersonal behaviors Changing a colostomy bag. The nurse has received the change-of-shift report. Discuss the issue with the leader of the "best practices" committee. c. I suggest you talk with a mental health counselor about your concerns d. Establishing the client's secondary medical diagnoses, b. Performing passive range of motion (ROM) on the client with right sided paralysis. In which harmonic number n is the string vibrating? 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. 3. The below statement corresponds to a numbered sentence in the passage. 2. c. Inflate the balloon when the urine flow stops Pain c. Include intact skin at the wound edges in the culture with this question, the nurse is using which of the following communication techniques? & 6. Drag and Drop the items from one box to the other. Place the client in a lateral position Try different methods of oral care on unresponsive clients to see what works best. The supervisor can only send one LPN/LVN to the floor. 3. Who should the nurse see first? Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. The surgeon initially prescribes a clear liquid diet. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. Identify and assess each incoming client. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. 4. Which nursing intervention should the charge nurse implement? 10. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. 1. 3. Documentation of what occurred, and the client's assessment is required in the nurse's notes. Determining the client's length of stay Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. b. Massage any bony prominences to promote circulation Which client would be appropriate for the RN to assign to the LPN? a. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. Which of the following statements should the nurse make? b. 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. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Which of the following actions should the nurse take? Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. The last client would be the one needing dietary education. 1. c. Can you tell me why you chose me? Correct: Traction should never be relieved without a primary healthcare provider's prescription. b. Negligence A nurse is caring for a client who is scheduled for an elective surgical procedure. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. d. Wait to discuss the behavior in the presence of others, a. Which of the following statements should the preceptor make? 1. Incorrect: This client is exhibiting early signs of increased intracranial pressure. 2. A nurse is caring for a client who is immobile. 1. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department Review a low-sodium diet for a client who has hypertension. Suggest splitting the shift with another nurse. a. 1. This client is not the nurse's first priority. 3. Incorrect: The nurse is responsible for monitoring a client. Based on these findings, to which of the following providers should the nurse request a referral for the client? PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. This documentation should go to your manager. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Clients over the age of 65 must have a saline lock according to facility policy a. Obtain a bedside commode for the client's use a. Because the charge nurse observes and weighs . Describe the types of machining operations that can be performed on a lathe. This is not a situation that requires the LPN to notify the primary healthcare provider. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Start MgSO4 at 3g/hr IV Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? a. 2. This client is at a high risk of infection. c. Use intermittent eye contact However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Document what the nurse believes was the cause of the ulcer development Take several shallow breaths during the procedure This client can wait until the others are treated. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? A client requesting assistance packing his belongings for discharge later today., a. 2. d. Move to the opposite side of the pack and open the fourth flap, 54. 1. A client requesting assistance packing his belongings for discharge later today.. c. Initiate a liquid diet for the client C-section planning discharge, postpartum infection, mastectomy. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. 2. Which of the following responses should the nurse make? Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. Which of the following sites should the nurse plan to use to obtain the blood specimen? This would be out of the UAP's scope of practice. It is not a routine task. 1. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen Refuse the assignment, being prepared for disciplinary action. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? 2. A nurse is administering a cold therapy application to a client. 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. The nurse chooses to confront the client. 1. This situation is considered an external disaster which means the hospital will be expecting multiple victims. c. I will complete the smoking cessation program I started 4. 3. 1. a. I'll sit with my knees lower than my hips 3. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. The nurse is responsible for the assessment of all vital signs of post-op clients. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. They are likely to wait for others to initiate conversation Encourage clients and families to develop mutually appropriate visitation times. c. Helping the client into the shower Which of the following actions should the nurse perform when opening the sterile pack? which client would be an appropriate care assignment for this lpn? c. I will inspect my crutches everyday for signs of wear PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. What was the hint? & 3. Correct: Did you notice the hint? A nurse who is breastfeeding her 4 month old. Incorrect: This group of clients needs specialized care. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. d. Let's wait until tonight to see if he continues his behavior, 63. 55. Provides day to day direction and supervision to assigned direct patient care staff. Inform the client of the need to avoid irritants such as carbonated beverages. Determine which personnel could be sent to the command center. a. 3. 5. 3. During exacerbation, the client will have many diarrhea stools. Currently, your census is 11, with one empty bed. c. Rephrase statements the client does not hear Incorrect: The client does need to have food; however, there is another action that should be performed first. a. 1. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. Placing a washcloth in the bathroom sink prior to cleaning. A nurse is having difficulty caring for a client due to variables affecting the communication process. Draining the colostomy bag on a client with diarrhea. b. 4. Notify the charge nurse of the observations. This client is stable and predictable. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. Perform catheterization when you recognize the urge to void d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) Could you try contacting a support group Correct. Elderly client admitted 30 minutes ago with reports of constipation for four days. a. There may be a good reason that the tray was not served. 4. c. Notify the nurse manager 4. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Reach around the pack and open the top flap away from the body, 53. 4. 4. d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. Select all that apply The nurse does not know the skills of the new UAP. a. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. A client with exacerbation of COPD reporting dyspnea. a. 4., & 5. 1. Call the family of a client suffering from dementia to discuss long term care placement. Report of feeling pressure They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. 4. 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). An adolescent client post appendectomy reporting pain. A nurse is developing a plan of care for a client who practices Islam. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. It also helps the client deal with issues that are important to him), 19. A nurse is assessing a client who is experiencing prostatic hypertrophy. Each state BON differs in that also some have treatment programs they administer themselves. This is outside the scope of practice for the LPN/LVN. b. Assigning tasks to an AP 2. 1., 4., & 5. 3. A nurse is teaching a client about the physical effects of chemotherapy. b. I will come back later and we can talk b. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" A nurse is admitting a client from a long-term care facility. Which of the following responses should the nurse make? 2. 4. 3. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. There is a trailing zero after the prescribed dose. 1. What should the nurse do first? INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. The client is considered unstable until assessed by the nurse. Elderly client who fell and fractured the left femoral neck. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. 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. 1. c. Hallucinations at the onset of sleep 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). Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. 2. Observe the client before taking further actions A charge nurse is making client care assignments. The nurse should do this when repositioning is needed. Select all that apply A nurse is caring for a client who expresses anxiety about his impending surgery. 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. 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. Which of the following approaches should the nurse use when using confrontation? Which of the following methods should the nurse plan to use? c. Use an aggressive tone of voice Increased insulin production A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Electric cords behind the furnitrure A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. d. Do you think crying will help? Transfer essential medical record to the receiving facility. c. Complete an incident report c. Face shield The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. Elevating the head of the bed 30- 40 for the client post thoracotomy Monitor client for pain while assisting with ambulation. Administering IV pain medication to a two day post op client. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29. Which of the following actions should the nurse take first? Which of the following actions should the nurse take? 3. 2. Showing disapproval 2. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Decide which choice fits best in the blank. Document current functional status assessment 3. c. There is fluid leaking around the insertion site Ask the charge nurse to evaluate the intervention. 3. In what order should the emergency department triage nurse send these clients to a room for treatment? This task cannot be delegated to the LPN/LVN. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? a. A lack of rapid eye movement (REM) sleep A nurse asks a client to share personal stories. The charge nurse's best response is to first obtain the needed information to make the best decision. The RN with 2 weeks' experience on the postpartum unit. the nurse responds, "don't worry, no one will harm your family." a. Removing the client's dentures Which of the following physiological responses to prolonged immobility should the nurse expect? The abdominal pain is worsening. Remind the client to tell the nurse when he has to urinate Where on the body is each type of skin found? The cleint's family asks the nurse for info about this type of care. A high concentration of carbon monoxide can cause death Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. 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. If you give the magnesium citrate, which is a laxative, what will happen? Placing the traction weights on the bed to transfer the client to x-ray. 4. The women's health charge nurse is making assignments for the next shift. A nurse is caring for a client who is postoperative following abdominal surgery. b. Summarization 4. Besides yourself, there are the following staff: Your unit has 12 beds. The client attempted to climb over the side rails and fell Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. the nurse responds: "It must be very frustrating to encounter this kind of attitude." 1. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? This client needs careful monitoring and specialized care. 2. d. They disclose more personal information, a. 3. d. Providing information, a. If a sentence is already correct, write CCC. which of the following actions should the nurse perform? 1. Call the client's provider Rewrite each incorrect sentence to correct the error. 1. a. Clarifying A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Accept the client's behavior as confrontational. Relax her abdominal muscles when she lifts an object