What should the nurse do first? 1. 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. 2. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. Well, do you see the q.d.? Which of the following responses should the nurse provide? Determine caregiver's stress level and coping strategies. 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. b. I should call my doctor if I find it harder to concentrate In which harmonic number n is the string vibrating? 4. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. 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. 4. Yes! Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Right forearm Empty the drainage bag at least every 8 hrb.) The third client would be the one needing a dressing change. D. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? c. Check to see if the suction equipment is working a. Incorrect: No, the monitoring is too specific for the med-surg nurse. 7. Incorrect: The RN is responsible for assessment and evaluation. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. This is likely cholelithiasis, which will need to be checked out. This service focuses on teaching the primary caregiver to meet the client's needs Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Which of the following actions should the nurse take? Correct: The unlicensed nursing assistant should not turn tube feedings off or on. a. Auscultating heart sounds 1. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. This is the most stable of the four clients which places this client last to be seen. a. The nursing supervisor may be able to assist with client care until another nurse can come in to work. A nurse receives a client care assignment from the charge nurse that he believes is unfair. 3. 1., 4., & 5. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 4. Assist a client to ambulate using a gait belt. 4. Wears a gown when entering the room of a client who requires contact precautions a. 4. Which of the following statements should the nurse make? A nurse who is 10 weeks pregnant. a. 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). Offer to take one of the clients. 1, 3 & 5. Making client care assignments As the RN charge | Chegg.com This protein is released by cells in the stomach. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? c. Providing anticipatory guidance to a client in crisis 1. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Documentation of what occurred, and the client's assessment is required in the nurse's notes. b. There are a total of 10 adult clients. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Which client would be appropriate for the RN to assign to the LPN? 3. & 6. b. I will bear the weight of my body on my hands Assist client to brush and floss teeth. Relax her abdominal muscles when she lifts an object Dexlansoprazole 30 mg PO daily. The nurse caring for the client at the time of death requests organ donation a. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 1. c. Discard any residual gastric contents 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. d. Do you think crying will help? The RN with 10 years' experience pulled from the ER. 2. 1. 3. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? A school-aged child with a fractured femur who is in balanced suspension traction. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. 1. A nurse is assessing a client who is experiencing prostatic hypertrophy. 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. 1., 4., & 5. The nurse asks why the client needs to know this. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". In the following sentences, circle each incorrectly used lowercase letter. Allow families unlimited visitation around the clock to meet their schedules. Schedule visiting times in two-hour increments so clients are not overwhelmed. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. Which task should the nurse take responsibility for completing? Monitor for GI upset 30 minutes after meals. 3. 1. In what order should the nurse assess assigned clients following shift report? Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. c. Review the client's progress toward personal objectives A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. A client receiving a blood transfusion that requires monitoring. a. b. Have a pen and paper handy Report of feeling pressure The nurse should do this when repositioning is needed. 2. b. He charge nurse is making client care assignments for the evening shift. 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. An LPN/VN has been floated to the emergency room following a chemical plant explosion. Evaluate client's safety risk factors. b. Irrigate the NG tube with 100 mL of sterile water Point out inconsistences in the client's behavior 1. A nurse is working with an assistive personnel (AP) to d. Ambulating the client in the hallway, c. Explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on affective learning), 80. The charge nurse needs additional information to make a decision. a. 1. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. A nurse is orienting a new assistive personal (AP) to the unit. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. b. a. Which of the following actions should the nurse take? Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Discuss the competency of the surgeon Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. 1. Select all that apply So what is wrong with option #1? What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? Select all that apply. Incorrect: This prescription is written correctly. A client receiving heparin injections for deep vein thrombosis. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. d. Reflection, c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation), 37. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. 4. This client is stable and predictable. In which situation should the nurse consult the client's advanced directive? 1. 4. 3. An experienced person who can research "best practice" regarding the issue is needed. Provides safe, effective delivery of patient care in . Administering IV pain medication to a two day post op client. Elderly client admitted 30 minutes ago with reports of constipation for four days. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. Transfer essential medical record to the receiving facility. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. 4. When a family member asks how respite care can help, which of the following responses should the nurse provide? The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? c. Explain the risks and benefits of the procedure b. 4. 3. Which of the following is the priority action by the nurse? d. Reduced blood viscosity, a. Auscultating heart sounds b. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? a. 3. Clients over the age of 65 must have a saline lock according to facility policy Both of these clients are terminal. Assign a nursing assistant to help the client with self-care activities. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. What is the best response by the charge nurse? The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. It happened so long ago - just get over it!" A charge nurse is making client care assignments. a. Phone report to the receiving nurse. It's unfortunate that I have to be in the hospital for this treatment d. Sleep apnea 1. NURSING ASSIGNMENT- delegation in the workplace | Studymonk This is not a situation that requires the LPN to notify the primary healthcare provider. 3. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. c. Irrigating a client's abdominal wound 2. The client attempted to climb over the side rails and fell b. Assigning tasks to an AP Ask the float nurse, "Have you been drinking?" Elizabeth Young BSN, RN-OCN - Registered Nurse - PIEDMONT CANCER Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. 2. Place the client in a lateral position What interventions can the nurse delegate to the LPN/VN? A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. 3. Showing disapproval Select all that apply Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. d. Mask, 83. The best practice committee works to improve clinical practice based on current research. 1. 2., 3. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. a. 212 Incorrect: The nurse retains the responsibility for the delegated task. b. a. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. 4. 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. 2. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter 4. 2. Occupational therapist 1. The charge nurse might not have realized all the responsibilities of taking this team of clients. The nurse has another priority. a. I will keep my walker at the end of my bed Drag and Drop the items from one box to the other. Which of the following actions is the nurse's priority? b. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Discussing a client's surgical procedure with the nurse manager Which of the following statements should the nurse identify as an indication that the client understands the instructions? Feed the client after warming the food. Which of the following client statements indicates an understanding of the procedure? The client can indicate desire for Do Not Resuscitate (DNR). Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 1. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. What is the primary factor for the charge nurse to consider when delegating care? b. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. d. I will begin once the client's insurance company approves discharge coverage, b. Correct: This group of clients is primarily med surgical. 1. A nurse has just finished a wound irrigation for a client who requires contact precautions. 2. The charge nurse is planning the staff assignments for the clients on a neurological unit. Which nurse should be assigned to care for this client? Select all that apply. Triage and assign color-coded tags to each client. 5. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. 2. Which of the following instructions should the nurse include? 4. Which action should the nurse interrupt the UAP from performing? 1. 2. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). 3. 2. a. All these clients have a GI problem. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. Which of the following findings should the nurse expect? 3. Incorrect: The client does need to have food; however, there is another action that should be performed first. Which of the following infection-control precautions should the nurse use caring for this client? A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Aplastic Anemia Support Group. b. Which of the following should the nurse include as a criterion for applying restraints? Observe the client before taking further actions b. 1. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. 4. 3. (Select all that apply) d. Identifying the client by name when making a referral for home health services, 30. Which of the following interventions should the nurse include? A nurse receives a client care assignment from the charge nurse that he believes is unfair. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. C-section planning discharge, postpartum infection, mastectomy. Which of the following findings should the nurse identify as a safety risk? Incorrect: The RN is responsible for teaching. This is an appropriate prescription. 1. d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. Which of the following indications should the nurse include? 2. 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. The nurse is planning care for a client admitted with Alzheimer's Disease. What was the hint? The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Request a prescription for a medication to ease the client's anxiety b. To which of the following rooms should the nurse assign the client? The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. a. The first vital sign check was performed by the nurse. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. 3. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. 4. 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. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Flashcards - chapter 7 - FreezingBlue Call the client's provider Tenderness over the symphysis pubis c. Changing a dressing, 78. a. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. the nurse responds, "don't worry, no one will harm your family." Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. The third client that should be sent back for treatment is the female client stating she has been raped. Client with chronic emphysema experiencing mild shortness of breath. 1. a. Auscultate breath should at least ever 2 hr Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. A nurse is assessing a client who has narcolepsy. 2. They are able to manage tasks related to basic care. American Sickle Cell Anemia Association 2. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. 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. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. d. Services are centered in long-term care facilities, a. Select all that apply For which of the following tasks should the nurse wear protective eye equipment. c. Raised toilet seats Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. a. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. The client with chronic emphysema has expected shortness of breath. This is a diabetic clinic. 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. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? b. Semi-formed stools are great news! Explain oral hygiene to a client receiving chemotherapy Placing the traction weights on the bed to transfer the client to x-ray. 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 . Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 3. 3. Only a plain enema or soap enema can be given by the UAP. The nurse voices his concern to the charge nurse. 4. b. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Besides yourself, there are the following staff: Your unit has 12 beds. 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. Serve food that have a hot/cold balance 5. The RN with 8 years' experience in the Intensive Care Unit. 3. Which referral would most likely be appropriate for the nurse to make? A client with atrial fibrillation currently on a diltiazem drip. Incorrect: This client does not have a predictable outcome. 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. a. These are appropriate tasks for an UAP to complete. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?