This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Which of the following actions should the nurse take? Changing a colostomy bag. Offer to take one of the clients. b. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Announce the new changes at the monthly staff meeting. Both of these clients are terminal. 1., 2., 3., & 4. b. Irrigate the wound with an antiseptic prior to obtaining the specimen Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Place the client in low Fowler's position In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. e. Dysuria, 49. Incorrect: This group of clients needs specific teaching. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. c. Decreased sodium excretion Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Which of the following activities should the nurse perform in this zone? Which of the following items should the nurse offer the client? This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. Two hours . Which of the following actions should the nurse take first? The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. b. Select all that apply. a. It would not be appropriate to overload this new employee with extra work. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. The nurse is using which level of communication at this time? Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 4. A nurse is prioritizing care for two clients at the start of the shift. 1. d. Discard the prepared medications and begin again after returning, d. I will wear synthetic clothing and woolen socks when using my oxygen (woolen and synthetic materials can generate static electricity and oxygen is a flammable gas - the client should wear cotton), 73. Most of the following sentences contain errors in the use of modifiers and comparisons. 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 lack of rapid eye movement (REM) sleep The nurse is caring for four clients. Incorrect: The nurse retains the responsibility for the delegated task. The third client that should be sent back for treatment is the female client stating she has been raped. 2. 2. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. b. Negligence Incorrect: The nurse is responsible for evaluating a client. d. Respite care is a continuation of psychological support after a family member dies. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. Now, in Option #2, we see a dangerous prescription. "Please explain what you mean by the word 'nervous'.". and 16 g of fat. The nurse voices his concern to the charge nurse. Turn on local news for up-to-date information on the train derailment. Incorrect: Atrial fibrillation places the client at risk for blood clots. Client prescribed antibiotics for cystitis. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. 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. What was the hint? 2. Protective Handoff and Nursing Report Sheet. 1. Speak to the UAP to determine what happened with the feeding. 1. a. 3. Asking for an explanation c. Review another client's similar surgical experience Places the soiled linen in the floor before bagging it a. Performing passive range of motion (ROM) on the client with right sided paralysis. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." d. Proceed with the preparation of the patient's surgical procedure, 15. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 1. Which task would be appropriate for the nurse to assign to an LPN/VN? The below statement corresponds to a numbered sentence in the passage. b. The client should be assessed first to rule out respiratory difficulty and hemorrhage. Alert all off-duty personnel to stand by in case of call- in. Anyone over age 18 can have an Advanced directive. 3. d. Anger, b. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. Prior to turning feeding back on, tube placement needs to be verified. Which of the following pieces of PPE should the nurse remove first? Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. b. I will call the doctor and get the prescription However, it remains true pain for this client and the client would need intervention to help manage this pain. To confirm the placement of the NG tube 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. c. Contact 1. Which of the following responses should the nurse make? c. Industry vs inferiority Client one day post kidney transplant. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 2. 1. c. Review a low-sodium diet for the client who has hypertension Injuries from a motor-vehicle accident can be life threatening. c. Discard the tablet and obtain another dose of medication This is normal for clients with hemorrhoids. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. c. Gender Sudden attacks of sleep Plan all care to be completed in early morning to allow afternoon for visitation. The nurse suggest that the family might need to respite care services. 3. c. Helping the client into the shower This client will also need a lot of education regarding anti-rejection medications. Review a low-sodium diet for a client who has hypertension. d. Determine if the client uses hearing aids, b. c. Paraphrasing d. Left forearm, b. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. Select all that apply. This stage involves constructive efforts on the part of the group members 3. Which of the following actions is an example of a violation of confidentiality? Providing hygiene care to a client who is HIV positive Assist client to brush and floss teeth. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. & 6. Change the subject when the client behaves defiantly 4. Autonomy vs shame and doubt Which of the following actions should the nurse take? Cystogram reporting burning on urination. 2. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. Incorrect: This would unnecessarily alarm the clients. The supervisor can only send one LPN/LVN to the floor. The nurse cannot allow the UAP to perform advanced tasks. Which of the following statements should the nurse identify as an indication that the client needs further instruction? a. Evaluate client's safety risk factors. Administering 3 g/hr IV of morphine would be extremely dangerous. Which of the following findings indicates that the client is meeting this goal? Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Administering IV pain medication to a two day post op client. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. The facility has insurance that will cover malpractice litigation c. Initiate a liquid diet for the client Correct: The medical nurse can be assigned to this client. The RN with 10 years' experience pulled from the ER. 3. 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. -Review a low-sodium diet for a client who has HTN
The charge nurse is planning assignments on a medical unit Which client Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner.
A Charge Nurse Role: The Ultimate Guide. a. c. Assist the client to the floor and begin mouth-to-mouth Empty the drainage bag at least every 8 hrb.) Report of feeling pressure c. One nurse lifting the client's legs as the client uses a trapeze bar Discuss the issue with the leader of the "best practices" committee. a. Elicit info from the client Answer the following question to test your understanding of the preceding section: Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Start MgSO4 at 3g/hr IV Sudden attacks of sleep Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. Confrontation should occur in the presence of a charge nurse or supervisor. This client should report an improved respiratory, not shortness of breath. d. Do you think crying will help? Make referrals to community services. Select all that apply Which of the following statements should the nurse identify as an indication that the client understands the discharge information? c. Hallucinations at the onset of sleep The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. What task would be best to assign to the LPN/LVN? a. Decreased or suppressed respiration are priority. Placing a washcloth in the bathroom sink prior to cleaning. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. 4. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. b. Emptying a urinary drainage bag for a client who has pneumonia Which client should be assigned to the most experienced nurse? This is a task that can be delegated to the LPN/LVN. Correct: This group of clients is primarily med surgical. Phone report to the receiving nurse. 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. 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. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 5. a. Place in priority order. A high concentration of carbon monoxide can cause death a. Clarifying Moistening the dentures prior to inserting them Increased insulin production c. 214 Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. 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 nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. 2. 5. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. 10. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. The nurse asks why the client needs to know this. If the client is unstable, the nurse would retain the role of measuring the vital signs. 4. Complete a client assignment sheet for the oncoming staff. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Based on this information,what should the nurse do? c. Can you tell me why you chose me? 3. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. b. a. I'll apply ankle to my ankle today and tomorrow 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 nurse responds: "It must be very frustrating to encounter this kind of attitude." Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 4.
1. A nurse is working with an assistive personnel (AP) to b. Which of the following actions should the nurse perform when opening the sterile pack? 1. 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.
Flashcards - chapter 7 - FreezingBlue 2. A nurse is planning care for a female client who has an indwelling urinary catheter. a. Each state BON differs in that also some have treatment programs they administer themselves. A nurse asks a client how he is feeling. d. Transporting a cerebrospinal fluid specimen to the lab 4. 77. c. Environment Notify clients that the disaster plan has been put into effect. Which of the following tasks should the charge nurse reassign to a licensed nurse? c. I should purchase a carbon monoxide detector for my home This service began with the client's admission to the hospital 6. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? Select all that apply a. Checking capillary refill beneath the client's fingernail Aplastic Anemia Support Group. b. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. 4. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. What is the best care assignment for this client? a. 1. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN.
Understanding the charge nurse's role in staffing c. Distended bladder The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. b. I will come back later and we can talk Allow families unlimited visitation around the clock to meet their schedules. Which of the following instructions should the nurse include? Gather supplies to prepare room for isolation. 4. b. b. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. d. Routine acquisition of a urine specimen A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. A client post pacemaker insertion, awaiting discharge instructions. b. }? benefactor of the world. 3. A nurse is completing discharge teaching with a client. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. Which of the following actions should the nurse take regarding informed consent? The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. a. I'll urinate a little then stop Select all that apply. 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. Remove tea and coffee from meal trays, b. Client with chronic emphysema experiencing mild shortness of breath. The key word in the stem is first. Ask the RN why the assignment is too heavy. Providing a passive response The nurse is reviewing some clients' prescriptions. What is the best response by the charge nurse? Ask the float nurse, "Have you been drinking?"
Read all the current literature related to oral care on unresponsive clients. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. Nothing life threatening. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which client would be appropriate for the RN to assign to the LPN? A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. The RN with 2 weeks' experience on the postpartum unit. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. The LPN should refuse the intervention. Initiative vs guilt 2. Which of the following info should the nurse include? Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? There will likely be both physical and emotional injury that needs attention, which places this client third. This client could be transferred with traction still maintained. d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. The nurse should use close-ended questions when assessing which of the following factors? Remember, pick the killer answer first! 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 charge nurse is observing a group of newly licensed nurses. Which actions should be instituted by each unit's charge nurse? INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. a. Bathtub with rails Hearing loss Rewrite each incorrect sentence to correct the error. - Assisting a client to ambulate using a gait belt. d. Droplet, d. Bend at the knees when picking up an object, 98. c. Nonfat milk The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. a. Auscultating heart sounds A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. We see that the temperature is already elevated, which makes us worry that infection is present. Briefly assess every client. 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. 1. a. a. It is quicker to administer medications intravenously in the hospital c. Foot b. 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. The client states, "I am so nervous about what the doctor might find during the test." Four clients arrive for their appointment at a diabetic clinic. 3. The client attempted to climb over the side rails and fell Relief of urinary retention 3. 3. 1. 1. b. Donation costs are the responsibility of the donor's family and estate 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. 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. 1. 1. Teach the UAP to change surgical dressings. A nurse is caring for a client who has emphysema and has difficulty with mobility. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. a. 5. 2. A nurse is preparing to move a client who is only partially able to assist up in a bed. In option #4, we see that the leading zero is missing from the prescription. A client who is disoriented and awaiting transfer to a long-term care facility. Client reporting a headache and has a fruity breath. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. b. 1. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions.
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