a charge nurse is making client care assignments

3. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. 1. The area surrounding the insertion site feels warm to the touch, 61. Incorrect. Incorrect: This response overlooks a potentially severe problem. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Which client can be assigned to the LPN? 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. 4. Select all that apply The nurse should call for immediate help so that a safe care environment is maintained for all clients. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. Which of the following actions should the nurse take? Client reporting a headache and has a fruity breath. 1. 4. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. a. A nurse is completing discharge teaching with a client. 3. What client should the nurse assess first? Complete a client assignment sheet for the oncoming staff. Two hours . 4. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Increased insulin production 3. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. c. Discard any residual gastric contents 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. d. What have you done in the past to cope with this issue? Correct: Communication is important in delegation, as is follow-up. 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). b. I'll rewrap my ankle starting from the knee down Temporary urinary retention (common for clients to develop after removal), 90. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) A client with an above the knee amputation reporting phantom pain. 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? Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. b. Notify the board of nursing (BON) that the float nurse is an alcoholic. Assist the float nurse with the clients case. 3. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. 3. 1. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. To remove gastric acid that might cause dyspepsia 2. Return any fresh linen not used for a client to the linen supply area a. Clarification 3. Which of the following actions should the nurse take? Talk to each nurse about concerns related to assigned clients. Write the letter of your choice on the answer line. This client is not the nurse's first priority. b. Assist a client to ambulate using a gait belt. b. Correct: Did you notice the hint? Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. 3. Which nursing intervention should the charge nurse implement? Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 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. A nurse who is 10 weeks pregnant. 2. Feedback d. When asking if the client took his medications this morning, 82. 3. 3. b. Which task should the nurse take responsibility for completing? 3. The nurse should not lecture, scold or argue with the float nurse. Drag and Drop the items from one box to the other. 4. 1. 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. 3. A charge nurse is making client care assignments. a. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? It can result in muscle spasm and tissue damage. The nurse considers various ideas submitted by team members. However, there are some basic points which are standard among all facilities. 2. 2. Which of the following actions should the nurse take? Remove all metal necklaces c. Helping the client into the shower Remind the client to tell the nurse when he has to urinate 2. a. d. Respite care is a continuation of psychological support after a family member dies. c. Notify the nurse manager The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. This client is at a high risk of infection. He charge nurse is making client care assignments for the evening shift. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Which of the following actions should the nurse include in the plan? Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. a. 1. Notify the charge nurse of the observations. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Place the client in low Fowler's position Client scheduled for breast reconstruction after mastectomy. 4. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. 5. _____The house that we lived in for nine years has been sold. This is normal for clients with hemorrhoids. 1., 4., & 5. Obtain a urine specimen from a client with an indwelling Foley catheter. Which of the following nontherapeutic communication techniques is the nurse using? a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter Incorrect: The concern here is the client being fed their meal. Read all the current literature related to oral care on unresponsive clients. Which of the following items should the nurse offer the client? a. Battery The expected standard of care was strict bed rest), 96. There is a trailing zero after the prescribed dose. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 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 Which of the following client statements should indicate to the nurse the need for additional teaching? Remind the client to avoid tight fitting clothes. 4. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago Select all that apply. In what order should the emergency department triage nurse send these clients to a room for treatment? c. I'll need to shave the hair off the skin where I place the electrodes Make nursing assignments appropriate to the skill level . Client prescribed antibiotics for cystitis. b. a. A nurse is preparing medication for a client when another client has an emergency. Patient safety must remain the priority. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. It contains a blank and is followed by four answer choices. 1. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. 4. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage 2. The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. The facility has insurance that will cover malpractice litigation In which situation should the nurse consult the client's advanced directive? Nurses Report Sheet Template Nicu. A charge nurse is making client care assignments. Place in priority order. A nurse is caring for a client who frequently attempts to remove his IV catheter. 2. This client is stable and predictable. leadership management of care nurse on unit is providing care for group of clients. 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. 3. Client diagnosed with inoperative brain tumor who is confused. a. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. A client receiving a blood transfusion that requires monitoring. Assist a client to ambulate using a gait belt 3. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Encourage the client to be more cooperative. Reach around the pack and open the top flap away from the body d. I will begin once the client's insurance company approves discharge coverage, b. Which of the following findings should the nurse identify as a safety risk? Notify the primary healthcare provider of transfer completion. Try different methods of oral care on unresponsive clients to see what works best. A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. b. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Twist at the waist when she moves an object to one side 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. 3. A charge nurse is making assignments for an oncoming shift. 1. Select all that apply b. Initiative vs guilt The women's health charge nurse is making assignments for the next shift. Aplastic anemia is a rare but serious condition. 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. a. Which of the following actions by the nurse is considered an indirect nursing care activity? Based on these findings, to which of the following providers should the nurse request a referral for the client? 2. Which of the following tasks should the nurse delegate to assistive personnel (AP)? a. I will begin 48 hr before the client's discharge d. Social conversation, a. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. Notify the primary healthcare provider. 1. The nurse should assess the client for which of the following expected outcomes after catheter removal? Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Send a day's worth of medications with the client to the receiving facility. 3. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. d. Transporting a cerebrospinal fluid specimen to the lab The client attempted to climb over the side rails and fell The client should be assessed first to rule out respiratory difficulty and hemorrhage. 6. d. 216, 22. Incorrect: Informing is the same thing as teaching. 4. A nurse is caring for a client who is immobile. 1. Decide which choice fits best in the blank. One nurse lifting as the client pushes with his feet 2., 3. This client will also need a lot of education regarding anti-rejection medications. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 3. Use adult diapers to prevent frequent clothing changes A nurse has just finished a wound irrigation for a client who requires contact precautions. Besides yourself, there are the following staff: Your unit has 12 beds. Which of the following actions should the nurse take regarding informed consent? After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. The client reports constipation for 4 days which may be an indication of worse problems. 3. Which of the following statements should the nurse identify as an indication that the client requires further clarification? 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." Which of the following actions is an example of a violation of confidentiality? Fruity breath. The RN with 8 years' experience in the Intensive Care Unit. c. Inform the surgical team to cancel the client's surgery You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Everything will be okay 3. No! Once the client is stable, the UAP could perform this task. a.) Client to receive dietary education. 1., 2., 3., & 4. 4. 1. a. Bathtub with rails Incorrect: This group of clients needs specialized care. Confrontation should occur in the presence of a charge nurse or supervisor. Incorrect: It is out of the UAP's scope of practice to administer medication. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. The body needs vitamin B12 to make red blood cells. 2. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? Ask the RN why the assignment is too heavy. 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 is responsible for the assessment of all vital signs of post-op clients. a. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. 1. What is the appropriate assignment? Start MgSO4 at 3g/hr IV c. Industry vs inferiority b. 1. 3. a. I'll sit with my knees lower than my hips Removing the client's dentures 3. 1. b. 2. 4. c. They tend to use more verbal communication This is an appropriate and safe action for the unlicensed nursing assistant to do. Which clients should be assigned to the CNA? 4. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. b. Focus on the client's present circumstances instead of his personal stories a. The nurse does not know the skills of the new UAP. 4. Which of the following actions is the nurse's priority? 4. Ask client if they are eating small, frequent meals. d. Lean back in the chair, b. 3. d. Remove tea and coffee from meal trays, b. Complete blockage of the large intestine. a. Elicit info from the client A nurse is developing a plan of care for a client who practices Islam. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. 4. 1. Encourage the client to use self-exploration The nurse has received the change-of-shift report. 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. b. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Which client would be appropriate for the RN to assign to the LPN? A nurse asks a client how he is feeling. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. b. The client is apparently stable and does not require any advanced assessment skills or specialized care. a. Which of the following actions is the priority for the nurse to include in the client's plan of care? Which nurse should be assigned to care for this client? Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. The client post PEG placement is stable. 3. Nurses dependent on drugs or alcohol can harm clients. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. The abdominal pain is worsening. Only the state Board of Nursing can legally determine the LPN's scope of practice. b. Negligence 1. d. What have you done in the past to cope with this issue? Each state BON differs in that also some have treatment programs they administer themselves. a. Shakes the soiled linen to remove any toilet paper remnants 2. c. I'll clean the inside of the container with a wipe 3. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. 1. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? Witness the client's signature b. It is not a routine task. 3. This client needs ongoing monitoring which is within the scope of practice for the LPN. c. Measurement of residual urine after urination Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. 2. 3. Based on this information,what should the nurse do? 4., & 5. Explain to the RN that all the nurses have the same number of clients. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. 2. 2. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound Which of the following should the nurse include as a criterion for applying restraints? A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Determining the client's length of stay Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. 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. Allow families unlimited visitation around the clock to meet their schedules. Select all that apply This is not a situation that requires the LPN to notify the primary healthcare provider. 3. 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. 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. 1. The client then states, "I have changed my mind and do not want to have the procedure done." Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. is a new graduate in orientation. 3. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. the nurse responds: "It must be very frustrating to encounter this kind of attitude." 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. Relief of urinary retention 3. An increased temperature will have a direct effect on the brain's metabolism and function. 3. This is the most stable of the four clients which places this client last to be seen. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. *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. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Gown a. 3. 2. Which of the following types of communication breakdown does this response represent? The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. Well, do you see the q.d.? Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Rewrite each incorrect sentence to correct the error. What is the best first action for the nurse to take in order to achieve this goal? Correct: The unlicensed nursing assistant should not turn tube feedings off or on. c. I suggest you talk with a mental health counselor about your concerns 212 A nurse enters an older adult client's room to insert a saline lock. Notify clients that the disaster plan has been put into effect. A nurse is adhering to standard precautions while caring for a group of clients. 2. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Provide an adaptive feeding device for the client c. I'll bear weight on my ankle for 10 minutes every hour Which prescription should the nurse question and have corrected? Refuse the delegated intervention. Which of the following instructions should the nurse give to the client prior to the procedure? Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. c. Hallucinations at the onset of sleep A client requesting assistance packing his belongings for discharge later today., Left upper forearm Place in priority order. The client receives home health care and spends most of his day in a reclining chair. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Which region of the tRNA pairs with mRNA? Incorrect: This would unnecessarily alarm the clients. Incorrect: What seems to be going on with this client? Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. The RN with 2 weeks' experience on the postpartum unit. The client with cystitis is stable and has a predictable outcome. b. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? b. d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Nothing will get passed the complete blockage. This would be out of the UAP's scope of practice. d. They disclose more personal information, a. This service focuses on teaching the primary caregiver to meet the client's needs A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. Each ROM movement should be repeated 5 times during the session.

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