a charge nurse is making client care assignments
To which of the following rooms should the nurse assign the client? M2.4: Making Client Care Assignments-GECC As the RN charge nurse, you are preparing to make assignments for the oncoming shift on the medical- surgical unit. 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. 2. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. The LPN can monitor the wound and provide care to the PEG insertion site. a. Provides day to day direction and supervision to assigneddirect patient care staff . c. Check to see if the suction equipment is working Stand directly in front of the client Elderly client who fell and fractured the left femoral neck. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Elderly clients have special fluid and electrolyte issues after a fall. 2. A nurse is prioritizing care for two clients at the start of the shift. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. 2. d. What have you done in the past to cope with this issue? d. Highly concentrated urine, 91. 1. Try different methods of oral care on unresponsive clients to see what works best. 2. The situation should be explored before bringing the supervisor in on the situation. *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. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. c. One nurse lifting the client's legs as the client uses a trapeze bar 2. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. A client with fibromyalgia reporting generalized pain of 7 out of 10. The nurse is using which level of communication at this time? Confrontation should occur in the presence of a charge nurse or supervisor. 3. b. b. Donation costs are the responsibility of the donor's family and estate The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Feed the client after warming the food. Fruity breath. Documentation of what occurred, and the client's assessment is required in the nurse's notes. Select all that apply Call the family of a client suffering from dementia to discuss long term care placement. 2. Perform the Heimlich maneuver 1. Which client can be assigned to the LPN? What information should the nurse include? Prior to turning feeding back on, tube placement needs to be verified. Licenced practical nurses are a little less educated than registered nurses. d. What have you done in the past to cope with this issue? Education Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. The nurse has just completed a 12 hour shift. The client can indicate desire for Do Not Resuscitate (DNR). Focusing Decide which choice fits best in the blank. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Besides yourself, there are the following staff: Your unit has 12 beds. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? 3. 4. 5. The nurse asks why the client needs to know this. a. a. Explore the client's feelings 2. b. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. During exacerbation, the client will have many diarrhea stools. is a new graduate in orientation. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Provides day to day direction and supervision to assigned direct patient care staff. Teach the UAP to change surgical dressings. A nurse is orienting a new assistive personal (AP) to the unit. Which response by the LPN is appropriate in response to the inappropriate delegation? d. I have a set of my brothers' crutches in the basement I can also use, a. 2. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Incorrect: Medications are not transferred with the client to a new facility. 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. Which of the following physiological responses to prolonged immobility should the nurse expect? A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. 3. However, providing care for missing teeth would also be within the LPN scope of practice. 3. d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. a. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. This service began with the client's admission to the hospital A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Which of the following statements should the nurse make? Which of the following statements should the nurse identify as an indication that the client needs further teaching? Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Assist the float nurse with the clients case. a. I will keep my walker at the end of my bed 1., 2., 3., & 4. 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. 2. Providing hygiene care to a client who is HIV positive Which of the following actions should the nurse take? A client with a fractured right humerus who reports the cast is too tight. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. An adult (18 years or older) can create an advanced directive. This situation is considered an external disaster which means the hospital will be expecting multiple victims. Clients over the age of 65 must have a saline lock according to facility policy Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. 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. 3. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. These are appropriate tasks for an UAP to complete. So what is wrong with option #1? Involve the client in their plan of care. Client who is a diabetic experiencing diabetic neuropathy. C. Review a low-sodium diet for a client who has hypertension. Provides safe, effective delivery of patient care in . Which client should be assigned to the most experienced nurse? and 16 g of fat. Allow families unlimited visitation around the clock to meet their schedules. (SATA) -Bathing a client who had an amputation 2 days ago. 4. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Incorrect: This group of clients needs specialized care. There is a trailing zero after the prescribed dose. Select all that apply a. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. Most of the following sentences contain errors in the use of modifiers and comparisons. The key word in the stem is first. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. In option #4, we see that the leading zero is missing from the prescription. c. Include intact skin at the wound edges in the culture Nothing life threatening, but an assessment needs to be made regarding the ulcer. 1. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? b. Which of the following activities should the nurse perform in this zone? 3. 2. a. What should the nurse do first? In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. This client needs ongoing monitoring which is within the scope of practice for the LPN. The nurse caring for the client at the time of death requests organ donation which client would be most appropriate to assign a licensed practical nurse (lpn)? A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? What was the hint? Based on these findings, to which of the following providers should the nurse request a referral for the client? c. Blood-tinged urine 2. Gown A list of current medications is sent to the facility. This is an appropriate and safe action for the unlicensed nursing assistant to do. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Which clients should be assigned to the CNA? c. Paraphrasing 5. A client with COPD complaining of shortness of breath on exertion. Select all that apply a. a. The surgeon initially prescribes a clear liquid diet. Drag and Drop the items from one box to the other. 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. c. Washes and rinses her hands for 10 seconds A nurse who is on hormone replacement therapy. butter, which contain 16 g of protein, 7 g of carbohydrates, Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. 2. a. 2. 3. Checking capillary refill beneath the client's fingernail Removing the abdominal dressing d. Motor impairment, 84. The provider must renew a restraint prescription every 8 hr. The healthcare team should recognize the client as the center of the team. Which of the following actions should the nurse take first? 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. 4., & 5. Which of the following infection-control precautions should the nurse use caring for this client? b. 2. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. 5. Which of the following statements should the nurse identify as an indication that the client understands the instructions? d. Transporting a cerebrospinal fluid specimen to the lab a. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." A nurse is preparing to move a client who is only partially able to assist up in a bed. d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). 4. Remind the client to tell the nurse when he has to urinate 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. Patient safety must remain the priority. Who should the nurse see first? 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. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. 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. This client can wait until the others are treated. 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. Administering 3 g/hr IV of morphine would be extremely dangerous. So, now you must decide which of these high priority clients should be seen in what order. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Sudden attacks of sleep Provide an adaptive feeding device for the client, 50. 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 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 c. I should purchase a carbon monoxide detector for my home The best practice committee works to improve clinical practice based on current research. Notify the board of nursing (BON) that the float nurse is an alcoholic. with this question, the nurse is using which of the following communication techniques? Client with cast to right leg requiring pain medication. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which referral would most likely be appropriate for the nurse to make? Injuries from a motor-vehicle accident can be life threatening. a. 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. c. They tend to use more verbal communication Lumbar puncture reporting a headache. c. Review a low-sodium diet for the client who has hypertension Limit the client's fluid intake in the evening 1. Encourage the client to be more cooperative. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Assign more daily tasks to the UAP. 1. Which region of the tRNA pairs with mRNA? c. Review another client's similar surgical experience The RN requests reassigning at least one of the clients to another nurse. 2. 4. Assist a client to ambulate using a gait belt. 1. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. a. Simply accept the assignment since overtime is mandatory. Place the client in low Fowler's position c. Offer the client personal thoughts and beliefs Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. 1. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? They are able to manage tasks related to basic care. 4. 3. Normally, red blood cells are flexible and round, moving easily through blood vessels. Notify clients that the disaster plan has been put into effect. TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. If you give the magnesium citrate, which is a laxative, what will happen? 1. This stage is when testing occurs to identify boundaries of interpersonal behaviors 3. The client with chronic emphysema has expected shortness of breath. 2. d. 216, 22. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. What client should the nurse assess first? Which of the following sites should the nurse plan to use to obtain the blood specimen? Which of the following actions should the nurse take? Discussing a client's surgical procedure with the nurse manager Right forearm Briefly assess every client. b. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. What was the rationale for this plan? a. A nurse is caring for a client who is postoperative following abdominal surgery. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? Incorrect: Is phantom pain something that is unexpected with above the knee amputations? b. A client requesting assistance packing his belongings for discharge later today., The client must understand the need for restraints A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Select all that apply Identify and assess each incoming client. Which clients would be appropriate assignments for the LPN/LVN? The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. c. Use an aggressive tone of voice a. b. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. Describe the types of machining operations that can be performed on a lathe. Use double bagging to remove soiled linen from the client's room Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? A client on a surgical unit frequently quarrels with the staff. 2. 2. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. d. Voided 30 mL frequently Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. 1. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Empty the drainage bag at least every 8 hrb.) Which of the following interventions should the nurse include? 3. b. A nurse is caring for a client who is scheduled for an elective surgical procedure. d. Identifying the client by name when making a referral for home health services, 30. A nurse is preparing a sterile field. Correct: Hot water may damage dentures so intervention is needed. Client one day post kidney transplant. a. Select all that apply Select all that apply. Four clients arrive for their appointment at a diabetic clinic. 1. 4. c. Decreased sodium excretion d. Remove and reinsert the NG tube, a. Underline the adjective clause in each sentence. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. e. Feed a client who had a stroke 3 months ago, 32. c. We administer all medications intravenously to clients in this unit 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. b. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. A client diagnosed with rheumatoid arthritis needing discharge teaching. 4. Also, making a surgical bed for the client returning from surgery is a basic procedure. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 3. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. A lack of rapid eye movement (REM) sleep The charge nurse is planning the staff assignments for the clients on a neurological unit. A nurse is completing discharge teaching with a client. d. I decline this opportunity at this time, b. b. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? Placing the traction weights on the bed to transfer the client to x-ray. The nurse has received the change-of-shift report. b. b. 5. The client should be assessed first to rule out respiratory difficulty and hemorrhage. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. d. Lean back in the chair, b. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. a. I will wear gloves when removing food from the freezer 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. 2. The nurse could definitely be part of the committee. Use the tablet's packaging to pick it up from the counter 1. 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 RN with 5 years' experience in the Labor and Delivery unit. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. It contains a blank and is followed by four answer choices.
