The client post PEG placement is stable. Which of the following explanations should the nurse provide? An Advance Directive includes a Living Will and a Medical Power of Attorney. These are appropriate tasks for an UAP to complete. A nurse is admitting a client from a long-term care facility. 6. The reason for the UAP not feeding the client needs to be determined. No! 4. 1. Report of feeling pressure which client would be an appropriate care assignment for this lpn? Request a prescription for a medication to ease the client's anxiety What information should the nurse include? What task would be best to assign to the LPN/LVN? The abdominal pain is worsening. Use the tablet's packaging to pick it up from the counter c. Holds the soiled linen against her body while carrying it to the linen bag 4. Which of the following statements should the nurse identify as an indication that the client requires further clarification? Temporary urinary retention Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. 4. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? 1. d. Perception The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. This is an elderly client who is a new admit. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. 5. b. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. Discuss the competency of the surgeon 4. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. Assist a client to ambulate using a gait belt. b. a. Removing the abdominal dressing 2) Assist a client to ambulate using a gait belt. c. Distended bladder leadership management of care nurse on unit is providing care for group of clients. b. A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. Identify and assess each incoming client. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. A client requesting assistance packing his belongings for discharge later today.. Select all that apply Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. A nurse is implementing direct nursing care for a group of clients in an acute care facility. 3. Performing passive range of motion (ROM) on the client with right sided paralysis. a. Feed a client that had a stroke 3 months ago. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. Estimate the number of Calories in two tablespoons of peanut 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. A nurse is adhering to standard precautions while caring for a group of clients. However, there are some basic points which are standard among all facilities. 1. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. (Select all that apply) d. Mask, 83. Although this will require assessment, this client is not the priority at this time. 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. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The client can indicate desire for Do Not Resuscitate (DNR). c. Confrontation Which referral would most likely be appropriate for the nurse to make? 1. 3. 4. It happened so long ago - just get over it!" c. One nurse lifting the client's legs as the client uses a trapeze bar It is within the LPNs scope of practice to administer antibiotics. Complete blockage of the large intestine. 3. Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. a. Select all that apply This determination is needed to assure client safety is being considered. Which of the following nontherapeutic communication techniques is the nurse using? To remove gastric acid that might cause dyspepsia The nurse could definitely be part of the committee. The nurse is reviewing some clients' prescriptions. Make nursing assignments appropriate to the skill level . 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. 4. Select all that apply A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. 2. Client scheduled for a dressing change to foot ulcer. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Those residing in long term care facilities benefit greatly from time spent with family or even older friends. a. 3. Nothing life threatening, but an assessment needs to be made regarding the ulcer. d. Proceed with the preparation of the patient's surgical procedure, 15. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. There are a total of 10 adult clients. b. I'll use the cleansing wipes from the front to back a. Handoff and Nursing Report Sheet. Solved 4. A charge nurse is making client care assignments. | Chegg.com c. Why are you crying? Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. The nurse is focusing on which of the following elements of the communication process? Personal liability coverage is not mandatory, but you should consider purchasing your own coverage 1. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". c. Do not eat or drink anything the morning of the test A nurse is admitting a client who has a partial hearing loss. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. b. Numbness Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. a. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. e. Feed a client who had a stroke 3 months ago, 31. Feed the client after warming the food. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 3. d. Message, 67. The client then states, "I have changed my mind and do not want to have the procedure done." Client two days post percutaneous endoscopic gastrostomy (PEG) placement. (Select all that apply.) As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. The best practice committee utilizes current research in their recommendations. Which of the following responses should the nurse make? The nurse prefers to check all vital signs on all clients. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. The nurse should call for immediate help so that a safe care environment is maintained for all clients. c. Take the client to the bathroom every 2 hr The RN with 10 years' experience pulled from the ER. 2. 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. Therefore, this would not be the most appropriate nurse to assign to this client. Which of the following pieces of PPE should the nurse remove first? A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. 3. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. This action is a defensive intervention, and does not address the quarrelsome behavior. The client's self-report of pain severity This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. b. 2. 8 Steps for Making Effective Nurse-Patient Assignments This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Relax her abdominal muscles when she lifts an object A skill for which the ap has received instruction the - Course Hero Turn on local news for up-to-date information on the train derailment. d. Sleep apnea Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Offer to take one of the clients. Which client should the nurse see first? Correct. c. There is fluid leaking around the insertion site b. Verbalize understanding of how the client feels Transfer essential medical record to the receiving facility. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 2. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Invite staff to contribute ideas on scheduling changes. a. A nurse is caring for a client who has emphysema and has difficulty with mobility. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? A nurse who is on hormone replacement therapy. Asking for an explanation The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? This client can wait until the others are treated. In order to reorganize staffing, the nurse manager should initiate which action first? 1. 2. The women's health charge nurse is making assignments for the next shift. Tenderness over the symphysis pubis c. The client's culture 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. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). The charge nurse's best response is to first obtain the needed information to make the best decision. 2. a. I will keep spare crutch tips handy 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. Schedule visiting times in two-hour increments so clients are not overwhelmed. a. Reposition the client every 3 hr A goal for this client is to use proper body mechanics at all times. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. a. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Everyone knows there are others who can chair this committee better than me Which clients should be assigned to the CNA? 4. 1. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 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. Return any fresh linen not used for a client to the linen supply area Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. b. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. c. Inflate the balloon when the urine flow stops The spouse can rescind the Advance Directive if the client becomes unresponsive. Monitor for GI upset 30 minutes after meals. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Start MgSO4 at 3g/hr IV A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. 2. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). A nurse asks a client to share personal stories. 1. 4. Feedback 3. 4. a. I'll urinate a little then stop Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Phone report to the receiving nurse. b. Dons gloves to empty a urinary drainage device Which of the following approaches should the nurse use when using confrontation? b. Summarization A home health nurse is conducting a home safety assessment for an older adult client. Which of the following tasks should the charge nurse reassign to a licensed nurse? Which of the following info should the nurse include? Check environment for potential safety hazards. Incorrect: The nurse is responsible for monitoring a client. d. I will place a bath seat in my shower to use when I bathe, b. 4. 4. Incorrect: The RN is responsible for assessment and evaluation. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. A nurse is having difficulty caring for a client due to variables affecting the communication process. 3. d. Counting radial pulse A nurse is preparing to obtain a blood specimen from a client by venipuncture. Comatose client with end stage chronic obstructive pulmonary disease. This is a diabetic clinic. Confrontation should occur in the presence of a charge nurse or supervisor. "Please explain what you mean by the word 'nervous'.". 4. b. Narrative interaction Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Include any relevant statements the client made about the ulcer In option #4, we see that the leading zero is missing from the prescription. 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 Autonomy vs shame and doubt 3. a. Question: A charge nurse is making client care assignments. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. Of my three brothers and sisters, my sister Giselle has the best sense of humor. A client with atrial fibrillation currently on a diltiazem drip. 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). Encourage clients and families to develop mutually appropriate visitation times. 3. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. 2. The nurse should initiate a referral with which of the following members of the interprofessional health care team? The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. 2. Write N next to the nonessential clauses and E next to the essential clauses. Incorrect: Moistening the dentures will ease insertion. (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. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Client with a T-5 spinal cord injury beginning rehabilitation therapy. 5. A nurse is planning to discharge a client who has quadriplegia to his home. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. b. Urinary frequency for several days The nurse has just completed a 12 hour shift. So what is wrong with option #1? d. I shouldn't advice you about what is ultimately a personal decision, b. A list of current medications is sent to the facility. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Measuring vital signs A charge nurse is making client care assignments. Yes! the nurse responds, "don't worry, no one will harm your family." 3. b. I'm so sorry to hear about this Which of the following actions indicates that the AP understands the principles of infection control? a. b. 1. Notify the primary healthcare provider. 3. a. 4. Elderly client who fell and fractured the left femoral neck. Two nurses lifting the client under the shoulders Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. c. Use an aggressive tone of voice Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? 2. (Select all that apply.). Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Which of the following statements should the nurse identify as an indication that the client understands the discharge information? What would the approximate meaning of photoelectric be, based on these root words? Wrapping the dentures in tissue while the client sleeps Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? d. Talk with the client's partner, b. Determine which personnel could be sent to the command center. (Select all that apply.). b. Reach around the pack and open the top flap away from the body, 53. A two-hour limit on visits discourages quality time. c. Discard any residual gastric contents a. 3. The nurse did not trust the new UAP. a. 1. Notify the nursing supervisor of the situation. Providing a passive response A charge nurse on an acute care unit is planning care for a client 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.