The client asks about his medications and their effects. 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. A nurse is caring for a client who has a hip fracture that requires surgical repair. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. Which of the following statements should the nurse identify as an indication that the client understands the instructions? 4. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). a. Clarification An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. The nurse has received the change-of-shift report. A nurse is developing a plan of care for a client who practices Islam. Focusing Draining the colostomy bag on a client with diarrhea. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? 4. Education INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Anyone over age 18 can have an Advanced directive. a. 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. Client to receive dietary education. A charge nurse is making client care assignments. Notify the primary healthcare provider. Place in priority order. Elevating the head of the bed 30- 40 for the client post thoracotomy Teaching insulin self administration cannot be delegated to the LPN. Comatose client with end stage chronic obstructive pulmonary disease. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. 4. c. They tend to use more verbal communication However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). A nurse is caring for a client who is about to have a colonoscopy. 5. b. eminent The nurse should initiate a referral with which of the following members of the interprofessional health care team? (SATA) -Bathing a client who had an amputation 2 days ago. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Client with a T-5 spinal cord injury beginning rehabilitation therapy. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. b. 2. What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? A client on a surgical unit frequently quarrels with the staff. a. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? Obtain a client's consent b. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. 3. a. 3. Explain administration is demanding a decreased overtime. Incorrect: The RN is responsible for collecting data. Placing the traction weights on the bed to transfer the client to x-ray. This task cannot be delegated to the LPN/LVN. c. I will inspect my crutches everyday for signs of wear Which of the following types of communication breakdown does this response represent? 2. b. Summarization LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. 4. Could you try contacting a support group Sit side-by-side with the client Evaluate pain relief after narcotic administration. The nurse voices his concern to the charge nurse. There may be a good reason that the tray was not served. a. Which of the following actions should the nurse take? Dr. Frankenstein had seen himself as a(n) ?\underline{? PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. b. Announce the new changes at the monthly staff meeting. 5. 1. a. Read all the current literature related to oral care on unresponsive clients. Incorrect: The charge nurse does not have to assess every client. Charge nurses have integral roles in healthcare organizations. A charge nurse is observing a group of newly licensed nurses. The nurse is responsible for the assessment of all vital signs of post-op clients. Client scheduled for a dressing change to foot ulcer. Changing the subject Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. 1., 4., & 5. c. Nonfat milk Suggest splitting the shift with another nurse. 4. 5. 6. e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. The cleint's family asks the nurse for info about this type of care. This service began with the client's admission to the hospital, 18. Client eating a simple-carb snack due to weakness. Monitor for behavioral changes. Correct: An LPN should be assigned clients with predictable outcomes. b. Wash the area of the puncture thoroughly with soap and water 2. The surgeon initially prescribes a clear liquid diet. A nurse is caring for a client who is scheduled for an elective surgical procedure. a. The charge nurse is making client assignments for a neuro-medical floor. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. The nurse should not be assigned to provide care if impairment is suspected. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? d. Respite care is a continuation of psychological support after a family member dies. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. 3. Select all that apply Which of the following interventions should the nurse include? 4. 1. a. 1. Places the soiled linen in the floor before bagging it 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. The nurse voices his concern to the charge nurse. Which of the following actions indicates that the AP understands the principles of infection control? c. Lock the medication in a room and finish preparing it after returning from the emergency The third client would be the one needing a dressing change. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 2. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter c. Document in the client's medical record that she completed an incident report a. Therefore, this would not be the most appropriate nurse to assign to this client. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. (Select all that apply.). b. 1. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. d. Anger, b. Which of the following items should the nurse include on the lunch tray? What action should the nurse implement first to ensure client safety? a. b. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Which of the following actions is the priority for the nurse to include in the client's plan of care? d. Left forearm, b. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. 3. There is a trailing zero after the prescribed dose. 1. The client would develop severe cramping. c. I'll bear weight on my ankle for 10 minutes every hour Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. 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. A nurse is caring for a client who states, "I have got to get out of this hospital! a. 1. 2. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? The infusion rate has stopped but the tubing is not kinked This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. b. c. Provide the client with a diet high in protein 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. A nurse is caring for a client who frequently attempts to remove his IV catheter. Respite care provides holistic support and care for a client who is terminally ill a. The client should be assessed first to rule out respiratory difficulty and hemorrhage. Occupational therapist 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. 1. Decide which choice fits best in the blank. Select all that apply Thus, the tasks involve successful management of the charge nurse's responsibilities. Start MgSO4 at 3g/hr IV c. Tie linen bags securely at the top 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. b. What was the hint? 1. c. We administer all medications intravenously to clients in this unit Incorrect: The nurse retains the responsibility for the delegated task. c. Distended bladder Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 2. Fruity breath. 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. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Asking for an explanation These are appropriate tasks for an UAP to complete. The nurse prefers to check all vital signs on all clients. Incorrect: The RN is responsible for assessment and evaluation. 4. a. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. 3. c. imaginary Which of the following actions should the nurse take? 212 The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. a.) Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. 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. A nurse is adhering to standard precautions while caring for a group of clients. A nurse is completing discharge teaching with a client. Incorrect: The RN is responsible for assessment and evaluation of clients. Which of the following instructions should the nurse include? They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. c. Can you tell me why you chose me? IV of D5 NS at 75 mL/hour with a 20 gauge catheter. a. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 3. b. Dons gloves to empty a urinary drainage device What task would be best to assign to the LPN/LVN? Incorrect: This group of clients needs specific teaching. c. When asking the client how he completes his ADLs 1. Nothing by mouth (NPO). a. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. The best practice committee utilizes current research in their recommendations. 1. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 1. d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. Have another nurse finish preparing the medications The primary healthcare provider may have suggestions but this is not the best first action. Which of the following statements should the nurse make? Which of the following instructions should the nurse give to the client prior to the procedure? Based on the information provided in report, which client condition should be the nurse's priority? c. The restraints should promote the client's safety and prevent injuries 2. 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: Atrial fibrillation places the client at risk for blood clots. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. 4. 1 A nurse is teaching a client who has a history of falls about home safety. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 3. A lack of rapid eye movement (REM) sleep 3. Determine caregiver's stress level and coping strategies. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Which of the following statements should the nurse identify as an indication that the client requires further clarification? Correct: The client has the right to be involved in the decision making of their care. Refuse the overtime assignment, being prepared for disciplinary action. Nothing life threatening, but an assessment needs to be made regarding the ulcer. a. Use double bagging to remove soiled linen from the client's room 2) Assist a client to ambulate using a gait belt. 2. Drag and Drop the items from one box to the other. a. 3. a. c. I should purchase a carbon monoxide detector for my home d. Reduced blood viscosity, a. Auscultating heart sounds c. Raised toilet seats Which of the following is the priority action by the nurse? 1. Return any fresh linen not used for a client to the linen supply area There are a total of 10 adult clients. Complete a client assignment sheet for the oncoming staff. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. A nurse is caring for a client who has a mental health disorder. What was the rationale for this plan? a. b. 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. c. Review a low-sodium diet for the client who has hypertension Ask the RN why the assignment is too heavy. b. The client with cystitis is stable and has a predictable outcome. 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. Licenced practical nurses are a little less educated than registered nurses. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. This could indicate a worsening of this client's condition. Photo comes from the Greek word for light. 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. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. Documentation of what occurred, and the client's assessment is required in the nurse's notes. This client can wait until the others are treated. Tenderness over the symphysis pubis 2. Determining the client's length of stay The nurse on a large surgical unit needs to evaluate several clients returning from procedures. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Prior to turning feeding back on, tube placement needs to be verified. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Which of the following responses should the nurse make? Besides yourself, there are the following staff: Your unit has 12 beds. 4. It would not be appropriate to overload this new employee with extra work. Risperidone .5 mg PO daily Which clients should be assigned to the CNA? e. an open perineal wound, 92. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. 1. a. Clarifying Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Assist ait to ambulate using a gait belt. Serve milk products separately from meals Client who has multiple injuries from a motor vehicle accident. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. b. 4. The nurse should use close-ended questions when assessing which of the following factors? Feed the client after warming the food. 4. (Select all that apply.) 3. (Select all that apply.). The supervisor can only send one LPN/LVN to the floor. b. I will begin once the client's discharge order is written A nurse is admitting a client from a long-term care facility. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. 4. This is an appropriate and safe action for the unlicensed nursing assistant to do.