Obtain a bedside commode for the client's use A charge nurse is making client care assignments. 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. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? This would be out of the UAP's scope of practice. The nurse does not know the skills of the new UAP. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. d. Determine if the client uses hearing aids, b. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Notify the primary healthcare provider of transfer completion. The client would develop severe cramping. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. A client requesting assistance packing his belongings for discharge later today.. Monitor for GI upset 30 minutes after meals. What task would be best to assign to the LPN/LVN? d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. e. Feed a client who had a stroke 3 months ago, 32. A nurse is filling out an incident report after finding a client lying on the floor. Which of the following client statements should indicate to the nurse the need for additional teaching? a. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Soaking the dentures in hot water Which of the following tasks should the nurse delegate to assistive personnel (AP)? a. e. an open perineal wound, 92. Incorrect: The client does need to have food; however, there is another action that should be performed first. The nursing supervisor may be able to assist with client care until another nurse can come in to work. However, there are some basic points which are standard among all facilities. A nurse wants to find out a better way to perform oral care on unresponsive clients. An increased temperature will have a direct effect on the brain's metabolism and function. c. Provide the client with a diet high in protein 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). A float nurse arrives on the unit to assist in the care of clients for the shift. Reach around the pack and open the top flap away from the body, 53. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? 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. Provide positive feedback to the UAP. 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. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Select all that apply. The nurse is reviewing some clients' prescriptions. There is a trailing zero after the prescribed dose. Which of the following instructions should the nurse include? Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. A nurse is teaching a client about the physical effects of chemotherapy. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. 1. 3. 2. The surgeon initially prescribes a clear liquid diet. c. Use intermittent eye contact They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. Call the client's provider Which of the following findings should the nurse identify as a safety risk? Select all that apply Which of the following statements should the nurse identify as an indication that the client understands the instructions? d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. Comatose client with end stage chronic obstructive pulmonary disease. 1. b. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. b. a. Feed the client after warming the food. 4. c. To determine the client's electrolyte balance b. Assigning tasks to an AP 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. Provide a between meal supplement to the client. 3. A nurse is caring for a client who is immobile. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. 1. Correct. The nurse should perform which of the following activities in this space? Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Which of the following actions should the nurse include in the plan? 3. d. Counting radial pulse, 100. 2. Which of the following actions indicates that the AP understands the principles of infection control? 4. which client would be most appropriate to assign a licensed practical nurse (lpn)? Make referrals to community services. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. assignmentcafe.com - A charge nurse is making assignments for nursing Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. A charge nurse is making client care assignments. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. c. Open the right flap with the left hand c. I'll need to shave the hair off the skin where I place the electrodes Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. What should the nurse do first? 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. 4. Place in priority order. This would be an acceptable task to assign to the UAP. Evaluate pain relief after narcotic administration. Providing a passive response Briefly assess every client. Removing the client's dentures b. c. Decreased sodium excretion Four clients arrive for their appointment at a diabetic clinic. 3. 4. This situation is considered an external disaster which means the hospital will be expecting multiple victims. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. a. a. 4. Reporting laboratory findings to a member of the client's family 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. An experienced person who can research "best practice" regarding the issue is needed. Alcoholic Anonymous b. 4. Which of the following tasks should the charge nurse reassign to a licensed nurse? Personal liability coverage is not mandatory, but you should consider purchasing your own coverage 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. a. I'll sit with my knees lower than my hips 1. 4. a. A nurse is preparing medication for a client when another client has an emergency. Which of the following actions is an example of a violation of confidentiality? 5. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. Which of the following actions should the nurse take? b. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. d. Respite care is a continuation of psychological support after a family member dies. Explain administration is demanding a decreased overtime. Which of the following actions is the nurse's priority? 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. 3. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. c. Inflate the balloon when the urine flow stops Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. 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. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. & 5. Administer sodium polystyrene sulfonate enema. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. A client who is disoriented and awaiting transfer to a long-term care facility. Notify the surgeon that the client wishes to withdraw informed consent for the procedure 3. Dr. Frankenstein had seen himself as a(n) ?\underline{? If a sentence is already correct, write CCC. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The RN requests reassigning at least one of the clients to another nurse. This client is not the nurse's first priority. This service focuses on teaching the primary caregiver to meet the client's needs 3. c. Confrontation a. The Role of the Registered Nurse as Charge Nurse 1. The report should contain consequences. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. 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). A skill for which the ap has received instruction the - Course Hero A charge nurse is making assignments for an oncoming shift. A nurse is admitting a client from a long-term care facility. A client diagnosed with rheumatoid arthritis needing discharge teaching. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. b. c. Offer the client personal thoughts and beliefs Ask the RN why the assignment is too heavy. 2. Select all that apply. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Nothing by mouth (NPO). This includes medication enemas. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. c. Lock the medication in a room and finish preparing it after returning from the emergency Removing the abdominal dressing Correct: Communication is important in delegation, as is follow-up. This is not a situation that requires the LPN to notify the primary healthcare provider. a. Elevating the head of the bed 30- 40 for the client post thoracotomy The charge nurse on the postpartum unit is making assignments. 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. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? What options would be appropriate for the nurse to take? Incorrect: This response overlooks a potentially severe problem. A nurse is caring for a client who frequently attempts to remove his IV catheter. The client receives home health care and spends most of his day in a reclining chair. The client states, "I'm feeling a bit nervous today." A goal for this client is to use proper body mechanics at all times. A charge nurse is making client care assignments. Send a day's worth of medications with the client to the receiving facility. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Printable Nursing Brain SheetPrintable Nursing - soyu.caritaselda.es (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Nurses Report Sheet Template Nicu. When the licensed person cannot determine this, the task should not be delegated. a. Bathe a client who had an amputation 2 days ago Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. b. The client attempted to climb over the side rails and fell Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. He charge nurse is making client care assignments for the evening shift. Remember, pick the killer answer first! 2. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 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. The nurse has just completed a 12 hour shift. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 3. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. This client is stable and predictable. 3. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. 2. 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? Discuss the competency of the surgeon Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. 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. d. Remove and reinsert the NG tube, a. Incorrect: This would unnecessarily alarm the clients. The client can indicate desire for Do Not Resuscitate (DNR). c. Blood-tinged urine 2. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. 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. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). 3. Incorrect: The nurse cannot assign teaching to the UAP. a. 1. 5. 3. 4. The nurse caring for the client at the time of death requests organ donation 4. b. Risperidone .5 mg PO daily 2., 3. 5. d. Identifying the client by name when making a referral for home health services, 30. a. 1. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. It is quicker to administer medications intravenously in the hospital 2. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. The client reports constipation for 4 days which may be an indication of worse problems. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. Which client would be appropriate for the RN to assign to the LPN? (Select all that apply.) For which of the following actions should the nurse intervene? What information should the nurse include? Encourage client to express grief related to loss of independence. 1., 2., & 5. Which of the following nontherapeutic communication techniques is the nurse using? To which of the following rooms should the nurse assign the client? Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions by the nurse is considered an indirect nursing care activity? Which of the following tasks should the nurse delegate to AP? Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. Schedule visiting times in two-hour increments so clients are not overwhelmed. A medical-surgical LPN has been sent to a short-staffed pediatric unit. 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. Which of the following findings associated with urinary retention should the nurse expect? Select all that apply It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. 3. 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. Report the incident to the charge nurse -Review a low-sodium diet for a client who has HTN c. I will complete the smoking cessation program I started b. Urinary frequency for several days 4. 1. Respite care provides holistic support and care for a client who is terminally ill The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. The charge nurse needs additional information to make a decision. A nurse enters an older adult client's room to insert a saline lock. 4. 1. Serve food that have a hot/cold balance The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. The reason for the UAP not feeding the client needs to be determined. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Correct: The medical nurse can be assigned to this client. ATI Leadership and Management Questions - Leadership Management of Care Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. (Select all that apply.) The best practice committee utilizes current research in their recommendations. A nurse is caring for a client within the intimate zone of the client's personal space. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 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. In option #4, we see that the leading zero is missing from the prescription. When asking the client about his receptiveness to the transfer Select all that apply The nurse is using which of the following therapeutic communication techniques? Remind the client to avoid tight fitting clothes. This is outside the scope of practice for the LPN/LVN. 6. Place the client in a lateral position 5. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 4. 2. What is the major histological difference between thick and thin skin? c. Initiate a liquid diet for the client the nurse should delegate collection of which of the following specimens to DismissTry Ask an Expert Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Harvard University University of Georgia Maryville University ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. 3. leadership management of care nurse on unit is providing care for group of clients. d. principal. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Client scheduled for a dressing change to foot ulcer. 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. 2. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. A client with epilepsy reporting an odd smell in the room. Clients over the age of 65 must have a saline lock according to facility policy Evaluate client's safety risk factors. Prior to turning feeding back on, tube placement needs to be verified. b. I can detect the presence of carbon monoxide by a metallic odor Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Thoracentesis reporting shortness of breath. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. c. Hallucinations at the onset of sleep, 65. Fruity breath. 3. 1. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 5. a. a. Reach around the pack and open the top flap away from the body This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. Phone report to the receiving nurse. When determining if the client is eating a well-balanced diet 1., 2., 4., & 5. Review a low-sodium diet for a client who has hypertension. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Explore the client's feelings c. Tie linen bags securely at the top 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. the nurse responds, "don't worry, no one will harm your family." Nurses dependent on drugs or alcohol can harm clients. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. Providing hygiene care to a client who is HIV positive b. Summarization If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. Besides, a charge nurse is a leader on the floor and should possess .
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