4. A nurse is discussing the norming stage of the group development process with a student nurse. e. Throw rugs, 40. b. b. Select all that apply The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. a. I'll sit with my knees lower than my hips Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. a. c. Physical therapist Sudden attacks of sleep 3. Underline the adjective clause in each sentence. The nurse should assess the client for which of the following expected outcomes after catheter removal? Which of the following statements by the student indicates understanding of the discussion? a. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension. Richied5864 Richied5864 . 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. Document current functional status assessment 4. An increased temperature will have a direct effect on the brain's metabolism and function. b. 4. UAPs can assist with elimination and are taught how to measure output. Which of the following actions is the priority for the nurse to include in the client's plan of care? This task cannot be delegated to the LPN/LVN. A nurse is caring for a client whose partner asks to speak with the nurse. a. 1. 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. a. Semi-formed stools are great news! d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. a. b. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. Gather supplies to prepare room for isolation. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? b. Numbness Review the action of insulin therapy 3. 2. The healthcare team should recognize the client as the center of the team. b. Which clients should be assigned to the CNA? 1. The charge nurse needs additional information to make a decision. The nurse would then start the 24 hour urine once the 1st void has been discarded. (Select all that apply.) A charge nurse is planning client activities for the day. 2. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Stand directly in front of the client Feedback A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. 2. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. Which of the following instructions should the nurse give to the client prior to the procedure? Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Which of the following actions should the nurse take? A nurse is caring for a client who has a mental health disorder. Normally, red blood cells are flexible and round, moving easily through blood vessels. 2. a. Reposition the client every 3 hr Client with cast to right leg requiring pain medication. A nurse is admitting a client from a long-term care facility. Most of the following sentences contain errors in the use of modifiers and comparisons. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. a. 4. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. c. Decreased sodium excretion A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. The charge nurse might not have realized all the responsibilities of taking this team of clients. A nurse is creating a discharge plan. a. 4. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. d. Voided 30 mL frequently Select all that apply. 2., 3. A nurse just back from maternity leave. When a family member asks how respite care can help, which of the following responses should the nurse provide? What was the rationale for this plan? Which of the following approaches should the nurse use when using confrontation? _________________ (magnanimous), a. generous A nurse is administering a cold therapy application to a client. Incorrect: This response overlooks a potentially severe problem. 2. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." Decreased RBC production The nurse is using which level of communication at this time? The first vital sign check was performed by the nurse. d. Providing information, a. Ask the RN why the assignment is too heavy. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. The nurse who made the medication error should take which of the following actions first? 4. d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. a. a. A nurse is planning care for a female client who has an indwelling urinary catheter. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. 3. It is within the LPNs scope of practice to administer antibiotics. Hanging a new bag of total parenteral nutrition (TPN). TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . A client with an above the knee amputation reporting phantom pain. Which of the following physiological responses to prolonged immobility should the nurse expect? Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. c. Review another client's similar surgical experience b. Furosemide 40 mg PO q.d. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. a. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Perform range of motion (ROM) exercises at least 2-3 times daily IV of D5 NS at 75 mL/hour with a 20 gauge catheter. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? c. I will place an area rug at the entry of my bathroom Phone report to the receiving nurse. a. Broth Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Provide positive feedback to the UAP. A nurse is preparing a sterile field. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. 2. a. I'll provide more stimulation in his environment Which of the following findings associated with urinary retention should the nurse expect? 3. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. b. 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. This is outside the scope of practice for the LPN/LVN. d. Counting radial pulse 2. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. 4. 3. There is a trailing zero after the prescribed dose. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. What task would be best to assign to the LPN/LVN? A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. c. Irrigating a client's abdominal wound a. Incorrect: This client is exhibiting early signs of increased intracranial pressure. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. b. The client's self-report of pain severity, 88. Each state BON differs in that also some have treatment programs they administer themselves. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. c. Environment the nurse responds, "don't worry, no one will harm your family." Alcoholic Anonymous b. I'm so sorry to hear about this 1. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Feed a client that had a stroke 3 months ago. 4. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter 5. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. Document what the nurse believes was the cause of the ulcer development A nurse is performing care activities for a client in the zone of touch that requires his consent. 5. a charge nurse is making client care assignments for the day. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. b. Irrigate the wound with an antiseptic prior to obtaining the specimen Notify clients that the disaster plan has been put into effect. c. Why are you crying? 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. The primary healthcare provider may have suggestions but this is not the best first action. 1. a. The best practice committee works to improve clinical practice based on current research. 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. 4. The cleint's family asks the nurse for info about this type of care. Client prescribed antibiotics for cystitis. A family member requests that the nurse apply restraints. 1. Evaluate client's safety risk factors. A nurse asks a client how he is feeling. 4. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. a. I will keep spare crutch tips handy d. Respite care is a continuation of psychological support after a family member dies. Client eating a simple-carb snack due to weakness. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain c. Explain the risks and benefits of the procedure d. Custard c. Hallucinations at the onset of sleep 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. 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. A client with a fractured right humerus who reports the cast is too tight. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. 3. a. They are able to manage tasks related to basic care. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Encourage clients and families to develop mutually appropriate visitation times. c. Visual observation for nonverbal signs of pain Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. c. Review the client's progress toward personal objectives b. Notify the nursing supervisor of the situation. 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. Which of the following actions should the nurse take?
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