a charge nurse is making client care assignments a charge nurse is making client care assignments

3. b. A nurse has just finished a wound irrigation for a client who requires contact precautions. This documentation should go to your manager. Which referral would most likely be appropriate for the nurse to make? 1. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. The client was lying on the floor next to his bed INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Place the client in a lateral position c. Discard the tablet and obtain another dose of medication Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. c. I'll clean the inside of the container with a wipe a. Gloves 4. a. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. Incorrect: The RN is responsible for assessment and evaluation. 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. a. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. The client states, "I am so nervous about what the doctor might find during the test." An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. c. Helping the client into the shower A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. A client diagnosed with rheumatoid arthritis needing discharge teaching. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. 7. The situation should be explored before bringing the supervisor in on the situation. Assign more daily tasks to the UAP. *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. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Also, making a surgical bed for the client returning from surgery is a basic procedure. 1. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 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. Perform catheterization when you recognize the urge to void It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. 2. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Warm the feeding solution to the body temperature Alert all off-duty personnel to stand by in case of call- in. 3. A client with exacerbation of COPD reporting dyspnea. c. I suggest you talk with a mental health counselor about your concerns The nurse has received the change-of-shift report. Incorrect: What seems to be going on with this client? 3. A nurse is creating a discharge plan. 2. c. I will make sure my visitors smoke outside Which of the following is the priority action by the nurse? Which of the following statements should the nurse make? The nurse is reviewing some clients' prescriptions. To confirm the placement of the NG tube b. a. 5. A nurse is planning care for a female client who has an indwelling urinary catheter. These individuals are selected by the charge nurse, and do not have to be nurses. b. This is an appropriate prescription. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. One important aspect is encouraging the flow of ideas between management and staff members. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. b. eminent b. Which of the following actions should the nurse take? 2. The client asks about his medications and their effects. 5. a. Following a large hurricane, multiple clients arrive at the emergency room for treatment. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. Which of the following responses should the nurse make? 2. Perform the Heimlich maneuver The facility has insurance that will cover malpractice litigation Which of the following items should the nurse offer the client? The RN requests reassigning at least one of the clients to another nurse. Collecting I & O totals for unit clients at the end of shift. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? Client diagnosed with Guillain-Barre' who is receiving ventilator support. 4. d. Identifying the client by name when making a referral for home health services, 30. b. 3. 3. Pernicious Anemia Society a. 3. UAPs can assist with elimination and are taught how to measure output. a. The report should contain consequences. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Which of the following actions should the nurse take? "Please explain what you mean by the word 'nervous'.". Which of the following types of torts has the nurse committed? and 16 g of fat. 1. Explain administration is demanding a decreased overtime. 4. c. Confrontation Determine caregiver's stress level and coping strategies. which client would be an appropriate care assignment for this lpn? b. Gown Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). e. Throw rugs, 40. Feedback 3. Obtain a client's consent Incorrect: The charge nurse does not have to assess every client. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. A client with fibromyalgia reporting generalized pain of 7 out of 10. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. They are likely to wait for others to initiate conversation This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 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. 3. Stand directly in front of the client What task would be best to assign to the LPN/LVN? Discarding the first urine voided by the client starting a 24 hour urine test. A nurse is admitting a client from a long-term care facility. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. 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. Respite care provides holistic support and care for a client who is terminally ill A nurse has completed an informed consent form with a client. a. 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. d. Go to employee health services, b. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter Which response by the LPN is appropriate in response to the inappropriate delegation? Teach caregivers memory enhancement aids. Client reporting a headache and has a fruity breath. Initiative vs guilt 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). The nurse does not know the skills of the new UAP. 1. d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. 1, 3 & 5. 3. Four clients arrive for their appointment at a diabetic clinic. Twist at the waist when she moves an object to one side A nurse is caring for a client who is postoperative following an appendectomy. 4. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Which of the following actions should the nurse take? d. Custard The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. Wrapping the dentures in tissue while the client sleeps (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. a. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Send a day's worth of medications with the client to the receiving facility. d. Counting radial pulse The surgeon initially prescribes a clear liquid diet. Two nurses lifting the client under the shoulders Which action should the nurse interrupt the UAP from performing? The nurse should do this when repositioning is needed. Changing a colostomy bag. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. 3. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. Feed the client after warming the food. 10. 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. 1. d. Respite care is a continuation of psychological support after a family member dies. c. Respite care helps relieve pain and promote comfort Which task should the nurse take responsibility for completing? Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. 2. the nurse responds, "don't worry, no one will harm your family." 1. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 3. e. Suctioning a client's new tracheostomy tube, 93. d. Discussing intake and output The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. We see that the temperature is already elevated, which makes us worry that infection is present. A nurse is planning to discharge a client who has quadriplegia to his home. Client eating a simple-carb snack due to weakness. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Now, in Option #2, we see a dangerous prescription. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. The nurse cannot allow the UAP to perform advanced tasks. b. Wash the tablet off with alcohol and place it in a clean medicine cup a. I wish I didn't have to attach the electrodes to my skin 2. 3. The nurse has been assigned four clients. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 3. Which of the following actions should the nurse take to assist the client with feeding? In the following sentences, circle each incorrectly used lowercase letter. a. I'll urinate a little then stop The client states, "I'm feeling a bit nervous today." It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). (Select all that apply.). 5. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. Place in priority order. The nurse is responsible for the assessment of all vital signs of post-op clients. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. 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. This service focuses on teaching the primary caregiver to meet the client's needs 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. 3. This is likely cholelithiasis, which will need to be checked out. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. 4. c. Assist the client to the floor and begin mouth-to-mouth e. Dysuria, 49. 2. Teaching insulin self administration to a diabetic client. c. Hold an object away from her body as she lifts it Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Elevating the head of the bed 30- 40 for the client post thoracotomy Those residing in long term care facilities benefit greatly from time spent with family or even older friends. This client is not the nurse's first priority. b. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". Client scheduled for a dressing change to foot ulcer. Incorrect: This group of clients needs specific teaching. 4. a. Bathtub with rails The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). b. 6. The supervisor can only send one LPN/LVN to the floor. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. A client requesting assistance packing his belongings for discharge later today.. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. A nurse enters an older adult client's room to insert a saline lock. a. Select all that apply The assignment process requires constant evaluation and reevaluation of information and priorities. Denial Richied5864 Richied5864 . 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. 4. Dentures should be stored in a denture cup. c. Environment 3. c. Palpating for pedal edema Encourage clients and families to develop mutually appropriate visitation times. Remove all metal necklaces Call the family of a client suffering from dementia to discuss long term care placement. c. Visual observation for nonverbal signs of pain A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. 4. Question: A charge nurse is making client care assignments. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. 4. A client on a surgical unit frequently quarrels with the staff. d. Droplet, d. Bend at the knees when picking up an object, 98. 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. Remind the client that a signed informed consent form is a legally binding document Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Fruity breath. 2. Something new could have occurred with the clients, making the assignments too heavy. Speak to the UAP to determine what happened with the feeding. The third client would be the one needing a dressing change. 1. A nurse is assessing a client who is experiencing prostatic hypertrophy. a charge nurse is making client care assignments for the day. There is a trailing zero after the prescribed dose. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. Which of the following statements should the preceptor make? Sudden attacks of sleep 2. Incorrect: This group of clients needs specialized care. Assign a nursing assistant to help the client with self-care activities. 1 For which of the following tasks should the nurse wear protective eye equipment. b. 1. It also helps the client deal with issues that are important to him), 19. Once the client is stable, the UAP could perform this task. Wears a gown when entering the room of a client who requires contact precautions A nurse is implementing direct nursing care for a group of clients in an acute care facility. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. c. Behaving defensively 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. 4. Only a plain enema or soap enema can be given by the UAP. A client receiving a blood transfusion that requires monitoring. What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? b. Numbness Rewrite each incorrect sentence to correct the error. d. Message, 67. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. 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. Which of the following methods should the nurse plan to use? Which of the following info should the nurse include? The client asks the nurse, "Why do I need that? Select all that apply 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. A nurse is caring for a client who is scheduled for an elective surgical procedure. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. This individual should be provided appropriate comments of appreciation for this accomplishment. b. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. }? benefactor of the world. Incorrect: The concern here is the client being fed their meal. Ask the RN why the assignment is too heavy. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Initiate oxygen and IV lines as needed. The area surrounding the insertion site feels warm to the touch, 61. Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Suggest splitting the shift with another nurse. Irrigate a client's ear canal. 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. Announce the new changes at the monthly staff meeting. In what order should the emergency department triage nurse send these clients to a room for treatment? a. So, now you must decide which of these high priority clients should be seen in what order. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 4. d. Lean back in the chair, b. Correct. Select all that apply. Which of the following actions is an example of a violation of confidentiality? 3. Comatose client with end stage chronic obstructive pulmonary disease. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. 1., 2., & 5. Encourage the client to be more cooperative. A medical-surgical LPN has been sent to a short-staffed pediatric unit. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. Try different methods of oral care on unresponsive clients to see what works best. b. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. This stage is when testing occurs to identify boundaries of interpersonal behaviors Which of the following findings associated with urinary retention should the nurse expect? A client with atrial fibrillation currently on a diltiazem drip. A charge nurse is observing a group of newly licensed nurses. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 4. 1. 1. A nurse is developing a plan of care for a client who practices Islam. a. Tenderness over the symphysis pubis Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. b. Wash the area of the puncture thoroughly with soap and water 2. 3. A charge nurse is making client care assignments. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage c. Consensus evolves in this stage Incorrect: Moistening the dentures will ease insertion. A nurse is engaging in relationship counseling with a male client. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? (Select all that apply.). A nurse is caring for a client who is postoperative. 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. 4. Did you recognize ureterolithiasis as "kidney stones"? 3. d. Highly concentrated urine, 91. What is the appropriate assignment? Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Based on this information,what should the nurse do? The expected standard of care was strict bed rest), 96. 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). Based on these findings, to which of the following providers should the nurse request a referral for the client? A nurse is providing care to a client who is on strict bed rest following surgery. Clients over the age of 65 must have a saline lock according to facility policy b. Grape juice Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. 9. Prior to turning feeding back on, tube placement needs to be verified. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. Select all that apply b. Negligence a. Write N next to the nonessential clauses and E next to the essential clauses. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. Hearing loss d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. Client scheduled for breast reconstruction after mastectomy. There are a total of 10 adult clients. a. There will likely be both physical and emotional injury that needs attention, which places this client third. A nurse is caring for a client whose partner asks to speak with the nurse. The nurse considers various ideas submitted by team members. Which of the following actions should this nurse take? Performing passive range of motion (ROM) on the client with right sided paralysis. Which clients should be assigned to the CNA? 5. d. Left forearm, b. Make nursing assignments appropriate to the skill level . c. We administer all medications intravenously to clients in this unit Refuse the overtime assignment, being prepared for disciplinary action. Drag and Drop the items from one box to the other. Disconnect client's nasogastric (NG) tube suction to allow ambulation. c. I will cover the catheter so he cannot see it 1. Select all that apply. Offer to take one of the clients. The area surrounding the insertion site feels warm to the touch Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. Schedule visiting times in two-hour increments so clients are not overwhelmed. Narrative interaction Review a low-sodium diet for a client with hypertension. The nurse would then start the 24 hour urine once the 1st void has been discarded. 4. 3. 4. c. I'll need to shave the hair off the skin where I place the electrodes 3. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. & 6. He charge nurse is making client care assignments for the evening shift. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. Allow families unlimited visitation around the clock to meet their schedules. Elderly client who fell and fractured the left femoral neck. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Nothing life threatening. Encourage the client to use self-exploration Which of the following types of communication breakdown does this response represent? the nurse responds: "It must be very frustrating to encounter this kind of attitude." 2. 1. A float nurse arrives on the unit to assist in the care of clients for the shift. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable.