Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. 5. Risperidone .5 mg PO daily b. I'll do exercises that strengthen my abdominal muscles c. Palpating for pedal edema b. Limit the client's fluid intake in the evening We do not know the extent of her injuries based on what the option tells us. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding). Removing the client's dentures 1. A nurse is caring for a client who is postoperative following an appendectomy. Select all that apply Incorrect: The RN is responsible for assessment and evaluation of clients. c. When asking the client how he completes his ADLs Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Dexlansoprazole 30 mg PO daily. 4. Which of the following actions is an example of a violation of confidentiality? d. Lean back in the chair, b. The nurse prefers to check all vital signs on all clients. 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. d. Determine if the client uses hearing aids, b. A nurse is engaging in relationship counseling with a male client. A nurse is caring for a client within the intimate zone of the client's personal space. 1. a. I wish I didn't have to attach the electrodes to my skin Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 2. d. Routine acquisition of a urine specimen Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. There will likely be both physical and emotional injury that needs attention, which places this client third. A client diagnosed with rheumatoid arthritis needing discharge teaching. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. The last client would be the one needing dietary education. Providing a passive response Which of the following statements should the nurse identify as an indication that the client needs further teaching? Client scheduled for a dressing change to foot ulcer. Which of the following activities should the nurse perform in this zone? (Select all that apply.) Place in priority order. Which of the following RNs should not be assigned to this baby? There is a possibility that a hypothermia blanket may be prescribed. A nurse is caring for a client in the orientation phase of the nurse-client relationship. 4. Therefore, this would not be the most appropriate nurse to assign to this client. b. Grape juice b. Which of the following statements should the nurse identify as an indication that the client requires further clarification? Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Nurses dependent on drugs or alcohol can harm clients. 1., 2., 3., & 4. A nurse is caring for a client who states, "I have got to get out of this hospital! b. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day Write the letter of your choice on the answer line. Select all that apply b. Select all that apply. 4. The client would develop severe cramping. b. Irrigate the NG tube with 100 mL of sterile water Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. 1. Complete a client assignment sheet for the oncoming staff. Obtain a client's consent Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. 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. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? What was the rationale for this plan? Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. 1. In what order should the nurse see the clients? The area surrounding the insertion site feels warm to the touch Which of the following should the nurse identify as an interpersonal variable? 4. b. e. Dysuria, 49. Incorrect: The concern here is the client being fed their meal. Use adult diapers to prevent frequent clothing changes 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. Providing hygiene care to a client who is HIV positive Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. A nurse asks a client to share personal stories. Incorrect: This would unnecessarily alarm the clients. If a sentence is already correct, write CCC. A nurse has just finished a wound irrigation for a client who requires contact precautions. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client. This could cause a medical emergency. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which clients could be assigned to an LPN? When the licensed person cannot determine this, the task should not be delegated. (Select all that apply.). There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Clients over the age of 65 must have a saline lock according to facility policy The charge nurse might not have realized all the responsibilities of taking this team of clients. 2. 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. c. Can you tell me why you chose me? Ask the RN why the assignment is too heavy. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. 1. c. Assist the client to the floor and begin mouth-to-mouth Assign more daily tasks to the UAP. Which of the following actions is the priority for the nurse to include in the client's plan of care? There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. (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. Identify and assess each incoming client. 4. b. Emptying a urinary drainage bag for a client who has pneumonia 4. Which of the following actions should the nurse take? What action should the nurse implement first to ensure client safety? Collecting I & O totals for unit clients at the end of shift. An increased temperature will have a direct effect on the brain's metabolism and function. Client who is a diabetic experiencing diabetic neuropathy. Reach around the pack and open the top flap away from the body 4. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. 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. Reach around the pack and open the top flap away from the body, 53. c. I will complete the smoking cessation program I started 3. 5. a. Which action by an unlicensed nursing assistant would require the nurse to intervene? c. Behaving defensively a. Which of the following actions should the nurse take to assist the client with feeding? _____The house that we lived in for nine years has been sold. a. Sudden attacks of sleep 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. b. In the following sentences, circle each incorrectly used lowercase letter. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. c. Blood-tinged urine A nurse caring for a client is using active listening skills. c. I should purchase a carbon monoxide detector for my home Have a pen and paper handy Two hours . a. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. The RN with 10 years' experience pulled from the ER. 2., 3. leadership management of care nurse on unit is providing care for group of clients. Left upper forearm There may be a good reason that the tray was not served. 1. b. For which of the following tasks should the nurse wear protective eye equipment. a. 5. c. The nurse may serve as a witness to informed consent for organ donation This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. 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). (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 Encourage the client to be more cooperative. A nurse is developing a plan of care for a client who practices Islam. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. A client who is disoriented and awaiting transfer to a long-term care facility. Oral surgeon (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. b. I'll rewrap my ankle starting from the knee down Incorrect: Informing is the same thing as teaching. Gown 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. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Something new could have occurred with the clients, making the assignments too heavy. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. Incorrect: The nurse cannot assign teaching to the UAP. Delegate 2 nurses to work with the client. 4. a. A nurse is admitting a client who has a partial hearing loss. There are a total of 10 adult clients. Which of the following findings should the nurse expect? 2. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." However, it remains true pain for this client and the client would need intervention to help manage this pain. a. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Nurses Report Sheet Template Nicu. 4. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. A nurse is caring for a client who has a mental health disorder. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 77. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. Warm the feeding solution to the body temperature The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Talk to each nurse about concerns related to assigned clients. b. c. Shivering The cause of the fall may be cardiac, but the question does not indicate this. c. Review the client's progress toward personal objectives This service focuses on teaching the primary caregiver to meet the client's needs Remind the client to tell the nurse when he has to urinate A nurse just back from maternity leave. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago d. Services are centered in long-term care facilities, a. What would the approximate meaning of photoelectric be, based on these root words? Relief of urinary retention During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate? This assumption is not appropriate, and the feelings and concerns of the client should be addressed. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Remember, pick the killer answer first! A nurse is assessing a client at a follow-up clinic for acute low back pain. A charge nurse is observing a group of newly licensed nurses. Determine caregiver's stress level and coping strategies. 3. Assist a client to ambulate using a gait belt 1. The LPN/LVN can reinforce teaching. c. Visual observation for nonverbal signs of pain Monitor for behavioral changes. b. eminent Discarding the first urine voided by the client starting a 24 hour urine test. 5. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. b. I should call my doctor if I find it harder to concentrate Select all that apply A. Remind the client to avoid tight fitting clothes. and 16 g of fat. This service began with the client's admission to the hospital A nurse is caring for a client who has a wound infection. Complete blockage of the large intestine. Teaching about a medication The nurse should not lecture, scold or argue with the float nurse. The below statement corresponds to a numbered sentence in the passage. A cardiac step down unit has requested float staff because of multiple impending admissions. b. Moistening the dentures prior to inserting them The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Teaching insulin self administration to a diabetic client. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? b. 2. 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. Initiate oxygen and IV lines as needed. The nurse is caring for four clients. A client requesting assistance packing his belongings for discharge later today.. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. Refuse the delegated intervention. b. Besides yourself, there are the following staff: Your unit has 12 beds. Lumbar puncture reporting a headache. Select all that apply Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Which of the following responses should the nurse make? ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. This client needs ongoing monitoring which is within the scope of practice for the LPN. 1. 4. 1. Occupational therapist Correct: Hot water may damage dentures so intervention is needed. 5. b. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. Elevating the head of the bed 30- 40 for the client post thoracotomy Assist a client to ambulate using a gait belt. D. 3. a. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 1. Nothing by mouth (NPO). The nurse could definitely be part of the committee. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. 3. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. Select all that apply. c. Contact Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. 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. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12.
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