(Select all that apply.). Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Select all that apply. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Incorrect: The concern here is the client being fed their meal. Speak using his usual tone of voice b. 2. a. I will keep my walker at the end of my bed Assign a nursing assistant to help the client with self-care activities. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Increased insulin production Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 3. a. Gloves 2. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. Besides yourself, there are the following staff: Your unit has 12 beds. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 3. A charge nurse is making client care assignments. Estimate the number of Calories in two tablespoons of peanut Select all that apply. Which of the following actions should the nurse take prior to administering the tube feeding? What is the best response by the charge nurse? A nurse is caring for a client who has a wound infection. 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. 4. Decreased or suppressed respiration are priority. b. Irrigate the NG tube with 100 mL of sterile water 2. Use the tablet's packaging to pick it up from the counter So, the UAP can assist a client to brush and floss teeth. b. I'll do exercises that strengthen my abdominal muscles 3. a. 3. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Besides, a charge nurse is a leader on the floor and should possess . 1., 2., 4., & 5. Alert all off-duty personnel to stand by in case of call- in. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 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. Oral surgeon Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Select all that apply 1. Perform the Heimlich maneuver Based on these findings, to which of the following providers should the nurse request a referral for the client? A nurse is caring for a client who has a mental health disorder. Confrontation should occur in the presence of a charge nurse or supervisor. 1. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" This client is stable and predictable. Select all that apply However, it remains true pain for this client and the client would need intervention to help manage this pain. A nurse is implementing direct nursing care for a group of clients in an acute care facility. 1. Which response by the LPN is appropriate in response to the inappropriate delegation? This is an appropriate prescription. 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. 3. 1. In option #4, we see that the leading zero is missing from the prescription. b. Write the letter of your choice on the answer line. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. b. Assess the client a. c. Holds the soiled linen against her body while carrying it to the linen bag In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. 3. 1. Protective Correct: This group of clients is primarily med surgical. 3. Provides safe, effective delivery of patient care in . December 5, 2020. 3. a. 2) Assist a client to ambulate using a gait belt. A client with an above the knee amputation reporting phantom pain. In what order should the nurse see the clients? Irrigate a client's ear canal. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. The RN with 8 years' experience in the Intensive Care Unit. 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. 2. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. a. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 4. Nurses Report Sheet Template Nicu. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 6. Incorrect: This client is exhibiting early signs of increased intracranial pressure. The client then states, "I have changed my mind and do not want to have the procedure done." Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. a. Which of the following statements should the nurse identify as an indication the client needs further teaching? d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. Select all that apply Which task would be appropriate for the nurse to assign to an LPN/VN? Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? b. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. 4. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. b. Feedback 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. A nurse wants to find out a better way to perform oral care on unresponsive clients. a. d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. b. d. Discussing intake and output which client would be an appropriate care assignment for this lpn? The charge nurse might not have realized all the responsibilities of taking this team of clients. The client post PEG placement is stable. Currently, your census is 11, with one empty bed. Which of the following actions should the nurse take? _________________ (magnanimous), a. generous Select all that apply Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. Limit the client's fluid intake in the evening A nurse is preparing to move a client who is only partially able to assist up in a bed. 3. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) with this question, the nurse is using which of the following communication techniques? c. Tie linen bags securely at the top Which of the following tasks should the nurse delegate to AP? Following a large hurricane, multiple clients arrive at the emergency room for treatment. c. Notify the nurse manager 2. It would not be appropriate to overload this new employee with extra work. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. Incorrect: This again is assessment which is the role of the RN only. 7. & 4. 3. Hanging a new bag of total parenteral nutrition (TPN). c. Discard the tablet and obtain another dose of medication 5. (Select all that apply.) 3. Make nursing assignments appropriate to the skill level . A nurse is performing care activities for a client in the zone of touch that requires his consent. A nurse is teaching a client who has a history of falls about home safety. A nurse is adhering to standard precautions while caring for a group of clients. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Which of the following statements by the student indicates understanding of the discussion? Which of the following nontherapeutic communication techniques is the nurse using? Which of the following findings associated with urinary retention should the nurse expect? }? benefactor of the world. b. Which of the following info should the nurse include? b. Turn on local news for up-to-date information on the train derailment. 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. 3. Discuss the assignment with another LPN. - Assisting a client to ambulate using a gait belt. a. I will wear gloves when removing food from the freezer 4. Place in priority order. 212 Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. A nurse is teaching a client about carbon monoxide poisoning. Licenced practical nurses are a little less educated than registered nurses. 3. b. Remember airway, breathing and circulation (ABCs). Remind the client that a signed informed consent form is a legally binding document 3. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. a. 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. Feedback 3. c. Distended bladder Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 1. The RN requests reassigning at least one of the clients to another nurse. c. I will complete the smoking cessation program I started This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. 1. 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). Which of the following actions is the nurse's priority? Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. d. Bend at the knees when picking up an object, 99. c. Paraphrasing 6. 1., 4., & 5. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. D. This stage is when testing occurs to identify boundaries of interpersonal behaviors b. b. Relax her abdominal muscles when she lifts an object B. 2. a. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. 3. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. Incorrect: Moistening the dentures will ease insertion. a. To focus on effective learning with this client, which of the following interventions should the nurse use? A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. a. This individual should be provided appropriate comments of appreciation for this accomplishment. Notify the nursing supervisor of the situation. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. 3. Providing a passive response c. Interpersonal (interpersonal communication is face-to-face interaction with another person. 1.