a charge nurse is making client care assignments

A nurse is caring for a client who is scheduled for an elective surgical procedure. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? It would not be appropriate to overload this new employee with extra work. 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. 1., 3, & 4. The LPN/LVN can reinforce teaching. b. I'm so sorry to hear about this A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. The other options may be correct but are not the best first action. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Notify the board of nursing (BON) that the float nurse is an alcoholic. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Donning gloves and using a gauze pad to grasp and remove dentures 3. Have a pen and paper handy A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. b. I will try to anticipate and avoid stressful situations when possible Which of the following infection-control precautions should the nurse use caring for this client? A client receiving heparin injections for deep vein thrombosis. 3. 3. c. Foot 1., 2., 3., & 4. Assist a client to ambulate using a gait belt. c. Notify the nurse manager Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. A nurse is caring for a client who has a hip fracture that requires surgical repair. Two hours . b. a. b. b. 2. Which of the following actions is an example of a violation of confidentiality? 3. Use adult diapers to prevent frequent clothing changes Speak to the UAP to determine what happened with the feeding. 3. d. Respite care is a continuation of psychological support after a family member dies. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 2. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. A charge nurse is making client care assignments. Which of the following instructions should the nurse include? 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. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? Normally, red blood cells are flexible and round, moving easily through blood vessels. Include any relevant statements the client made about the ulcer, 64. A client with fibromyalgia reporting generalized pain of 7 out of 10. Which region of the tRNA pairs with mRNA? Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. 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. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. a. a. d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. Ask client if they are eating small, frequent meals. d. Providing information, a. a. The nurse should assess the client for which of the following expected outcomes after catheter removal? Which of the following actions by the nurse is considered an indirect nursing care activity? a. 1., 2., 3., & 4. They are likely to wait for others to initiate conversation A charge nurse is making client care assignments. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. Discuss the issue with the leader of the "best practices" committee. 3. Provide positive feedback to the UAP. The client should be assessed first to rule out respiratory difficulty and hemorrhage. b. 2. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. 4. A charge nurse is planning client activities for the day. b. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Document current functional status assessment The nurse has just completed a 12 hour shift. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. For which of the following tasks should the nurse wear protective eye equipment. b. Dons gloves to empty a urinary drainage device A charge nurse is making assignments for an oncoming shift. A client who is disoriented and awaiting transfer to a long-term care facility. Incorrect: The nurse cannot assign teaching to the UAP. d. 216, 22. 5. The client asks the nurse, "Why do I need that? Decreased or suppressed respiration are priority. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. A charge nurse is making client care assignments. b. 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. 4. Which of the following interventions should the nurse include? Change the subject when the client behaves defiantly a. Select all that apply. Which preoperative prescription should the nurse question? Two nurses lifting the client under the shoulders the nurse responds, "don't worry, no one will harm your family." Which clients should be assigned to the CNA? a. Broth 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. 4. Allow families unlimited visitation around the clock to meet their schedules. Correct: The UAP can remind the client to do something that has already been taught by the nurse. (Select all that apply) 5. 1. Which action should the nurse interrupt the UAP from performing? A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 3. 5. There is a trailing zero after the prescribed dose. In what order should the nurse assess assigned clients following shift report? a. Ambulating a client who is 2 days post vaginal hysterectomy It's just not the right time for me to do this Place in priority order. b. I'll rewrap my ankle starting from the knee down c. Distended bladder c. Leave a nightlight on in the client's room c. Physical therapist 4. It can result in muscle spasm and tissue damage. A nurse is caring for a client whose partner asks to speak with the nurse. Call the client's provider c. When asking the client how he completes his ADLs d. I shouldn't advice you about what is ultimately a personal decision, b. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. d. Counting radial pulse Which clients would be appropriate assignments for the LPN/LVN? a. Hypotension 1. 3. c. Washes and rinses her hands for 10 seconds, 11. 4. b. The nurse should not lecture, scold or argue with the float nurse. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. d. Do you think crying will help? Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. 4. 1. d. Let's wait until tonight to see if he continues his behavior, 63. Clients over the age of 65 must have a saline lock according to facility policy Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. Determine caregiver's stress level and coping strategies. 2. A nurse is teaching a client about carbon monoxide poisoning. a. Review a low-sodium diet for a client with hypertension. 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. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Use the tablet's packaging to pick it up from the counter d. Complete an incident report, 70. Client with cast to right leg requiring pain medication. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Which of the following activities should the nurse perform in this zone? 4. This client should report an improved respiratory, not shortness of breath. Report of feeling pressure 3. Announce the new changes at the monthly staff meeting. 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. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. b. Donation costs are the responsibility of the donor's family and estate Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. a. Assign more daily tasks to the UAP. The client's self-report of pain severity, 88. a. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. b. Select all that apply Vital sign measurement 1. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. 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. Empty the drainage bag at least every 8 hrb.) The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 3. Bargaining b. Summarization Correct: The medical nurse can be assigned to this client. Receive report from the emergency department (ED) on a new client. c. Review a low-sodium diet for the client who has hypertension 2. d. principal. 2. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? A nurse is caring for a client who expresses anxiety about his impending surgery. This is an elderly client who is a new admit. (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 The nurse considers various ideas submitted by team members. Aplastic Anemia Support Group. 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. 2. a. 2. 1. 1) Bathe a client who had an amputation 2 days ago. Focusing Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. The nurse is using which of the following therapeutic communication techniques? All these clients have a GI problem. b. eminent The best practice committee utilizes current research in their recommendations. is a new graduate in orientation. What information should the nurse include? 2. Drag and Drop the items from one box to the other. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Request a prescription for a medication to ease the client's anxiety 3. 3. The client is apparently stable and does not require any advanced assessment skills or specialized care. A nurse is completing discharge teaching with a client. If a sentence is already correct, write CCC. Teaching about a medication Which of the following nontherapeutic communication techniques is the nurse using? 2. Nothing will get passed the complete blockage. 4. A client requesting assistance packing his belongings for discharge later today.. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. a. c. Distended bladder Nothing life threatening, but an assessment needs to be made regarding the ulcer. c. 214 Based on these findings, to which of the following providers should the nurse request a referral for the client? The charge nurse knows what client would be most appropriate for this LPN? 3. 6. 6. What is the best response by the charge nurse? A client diagnosed with rheumatoid arthritis needing discharge teaching. 1. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. a. A nurse who is 10 weeks pregnant. d. The nurse has already considered alternatives to restraints, a. a. I'll provide more stimulation in his environment They are more direct when discussing issues 1. Which of the following indications should the nurse include? Notify the surgeon that the client wishes to withdraw informed consent for the procedure Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. 4. Correct: Hot water may damage dentures so intervention is needed. Remind the client to tell the nurse when he has to urinate b. We do not know the extent of her injuries based on what the option tells us. Comatose client with end stage chronic obstructive pulmonary disease. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. Besides yourself, there are the following staff: Your unit has 12 beds. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. The nurse has received the change-of-shift report. 2. 1. b. The charge nurse must triage and assign clients to appropriate staff. The client states, "I'm feeling a bit nervous today." 4. The third client that should be sent back for treatment is the female client stating she has been raped. 4. Documentation of what occurred, and the client's assessment is required in the nurse's notes. This is likely cholelithiasis, which will need to be checked out. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. Select all that apply. The client states, "I am so nervous about what the doctor might find during the test." Select all that apply Send a day's worth of medications with the client to the receiving facility. Elderly client who fell and fractured the left femoral neck. C. Review a low-sodium diet for a client who has hypertension. *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. b. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. 4. An LPN/VN has been floated to the emergency room following a chemical plant explosion. b. c. Assist the client to the floor and begin mouth-to-mouth In which situation should the nurse consult the client's advanced directive? The client's self-report of pain severity Limit the client's fluid intake in the evening c. Holds the soiled linen against her body while carrying it to the linen bag c. Blood-tinged urine 77. d. Discussing intake and output Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. Which of the following responses should the nurse make? a. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. 2. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. Assign a nursing assistant to help the client with self-care activities. b. 1. Notify the charge nurse of the observations. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. 8. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. Lumbar puncture reporting a headache. This service focuses on teaching the primary caregiver to meet the client's needs Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. 6. Relief of urinary retention Write N next to the nonessential clauses and E next to the essential clauses. (SATA) -Bathing a client who had an amputation 2 days ago. The nurse chooses to confront the client. A nurse is admitting a client who has a partial hearing loss. 2. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. 3. However, there are some basic points which are standard among all facilities. 6. A home health nurse is conducting a home safety assessment for an older adult client. Richied5864 Richied5864 . The option does not say the client is terminal, in a vegetative state, or in a coma. Channel A nurse asks a client how he is feeling. c. Include intact skin at the wound edges in the culture Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. Assist a client to ambulate using a gait belt The stem does not indicate any loss of neurological function resulting from the seizure activity. 3. b. Negligence An Advance Directive includes a Living Will and a Medical Power of Attorney. 4. 2. c. Paraphrasing (Select all that apply.) a. A client with epilepsy reporting an odd smell in the room. A family member requests that the nurse apply restraints. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. 1. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). Both of these clients are terminal. Client diagnosed with inoperative brain tumor who is confused. Which of the following items should the nurse offer the client? 1. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Removing the client's dentures Feed the client after warming the food. 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). b. c. There is fluid leaking around the insertion site Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. What is the best first action for the nurse to take in order to achieve this goal? b. A nurse who is breastfeeding her 4 month old. Turn on local news for up-to-date information on the train derailment. Answer the following question to test your understanding of the preceding section: 1. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. 4. 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. A client with a fractured right humerus who reports the cast is too tight. Feed a client that had a stroke 3 months ago. This would be out of the UAP's scope of practice. Client with chronic emphysema experiencing mild shortness of breath. Cardiac catheterization with a decreased pedal pulse below insertion site. d. Lean back in the chair, b.

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