This client needs careful monitoring and specialized care. Patient safety must remain the priority. 4. 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). Client diagnosed with inoperative brain tumor who is confused. 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. Elderly clients have special fluid and electrolyte issues after a fall. 1. 8. 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. Respite care provides holistic support and care for a client who is terminally ill b. I will bear the weight of my body on my hands 1. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. Allow families unlimited visitation around the clock to meet their schedules. Accept assignment, documenting personal concerns regarding work conditions. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. 4. 5. 2. c. Document in the client's medical record that she completed an incident report Currently, your census is 11, with one empty bed. a. Lisinopril 20.0 mg PO daily 1. The client is reporting anxiety, discomfort, and a feeling of bloating. 4. b. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. This would be out of the UAP's scope of practice. Monitor client for pain while assisting with ambulation. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. b. Teaching insulin self administration to a diabetic client. c. Hold an object away from her body as she lifts it c. Provide the client with a diet high in protein CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. 1. 3. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. Client one day post kidney transplant. A nurse is caring for a client who is postoperative following abdominal surgery. A nurse is developing a plan of care for a client who practices Islam. What action should the nurse take after mistakenly administering the wrong medication? d. Assault, b. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Only a plain enema or soap enema can be given by the UAP. This could indicate a worsening of this client's condition. c. Open the right flap with the left hand A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. d. Place the tablet directly into a medication cup, 36. c. Notify the nurse manager Identify and assess each incoming client. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. Incorrect: This client does not have a predictable outcome. Report of feeling pressure Client scheduled for breast reconstruction after mastectomy. 1. 1. A client requesting assistance packing his belongings for discharge later today., Select all that apply Which of the following actions should the nurse take prior to administering the tube feeding? Invite staff to contribute ideas on scheduling changes. 3. b. This service began with the client's admission to the hospital 2. 3. A nurse is filling out an incident report after finding a client lying on the floor. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). 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. Which of the following approaches should the nurse use when using confrontation? In option #4, we see that the leading zero is missing from the prescription. Speak to the UAP to determine what happened with the feeding. Correct: Did you notice the hint? 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. Currently, your census is 11, with one empty bed. 1. Providing a passive response The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Remind the client to avoid tight fitting clothes. This is likely cholelithiasis, which will need to be checked out. 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. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). (Select all that apply.). Elderly client who fell and fractured the left femoral neck. Vital sign measurement An increased temperature will have a direct effect on the brain's metabolism and function. A nurse caring for a client is using active listening skills. a. Clarification A medical-surgical LPN has been sent to a short-staffed pediatric unit. Which of the following actions should the nurse take first? Tenderness over the symphysis pubis c. Helping the client into the shower Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. A nurse is caring for a client who expresses anxiety about his impending surgery. b. A nurse is caring for a client who has a wound infection. 1. The spouse can rescind the Advance Directive if the client becomes unresponsive. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Incorrect: Moistening the dentures will ease insertion. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? a. a. I will keep spare crutch tips handy Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. 4. Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47. 4. This is an elderly client who is a new admit. c. Paraphrasing Document current functional status assessment 2. Warm the feeding solution to the body temperature 7. a. 1. d. I shouldn't advice you about what is ultimately a personal decision, b. Occupational therapist Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. c. Tie linen bags securely at the top A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Obtain a urine specimen from a client with an indwelling Foley catheter. b. Accept the client's behavior as confrontational. A charge nurse is making client care assignments. Soaking the dentures in hot water The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. 1. Client reporting epigastric pain and nausea after eating. The client should be assessed first to rule out respiratory difficulty and hemorrhage. Nothing life threatening. Incorrect: This response overlooks a potentially severe problem. Which actions should be instituted by each unit's charge nurse? Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 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. b. I'm so sorry to hear about this A client with a fractured right humerus who reports the cast is too tight. Which of the following statements should the nurse make? & 5. 4. d. Social conversation, a. b. Negligence Which of the following actions by the nurse is considered an indirect nursing care activity? 4., & 5. 5. A nurse wants to find out a better way to perform oral care on unresponsive clients. Which referral would most likely be appropriate for the nurse to make? 2. b. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. These are appropriate tasks for an UAP to complete. b. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 3. Write N next to the nonessential clauses and E next to the essential clauses. Document what the nurse believes was the cause of the ulcer development Once the client is stable, the UAP could perform this task. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Lumbar puncture reporting a headache. c. Assist the client to the floor and begin mouth-to-mouth 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. Client with ureterolithiasis who requires frequent PRN pain medication. The charge nurse should notify the nursing supervisor who will seek additional staff. Feedback Make nursing assignments appropriate to the skill level . Pain Which of the following actions should the nurse include in the plan? Normally, red blood cells are flexible and round, moving easily through blood vessels. Monitor for behavioral changes. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. b. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? c. Review a low-sodium diet for the client who has hypertension Which client can be assigned to the LPN? This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. 2. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. a. 2. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. d. I decline this opportunity at this time, b. A nurse is caring for a client within the intimate zone of the client's personal space. The surgeon initially prescribes a clear liquid diet. Which of the following actions should the nurse take? It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). d. Let's wait until tonight to see if he continues his behavior, 63. In order to reorganize staffing, the nurse manager should initiate which action first? (Select all that apply.). Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Cystogram reporting burning on urination. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. Which of the following actions should this nurse take? Risperidone .5 mg PO daily Something new could have occurred with the clients, making the assignments too heavy. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Besides yourself, there are the following staff: Your unit has 12 beds. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 1. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. d. I will place a bath seat in my shower to use when I bathe, b. Include any relevant statements the client made about the ulcer, 64. The infusion rate has stopped but the tubing is not kinked To remove gastric acid that might cause dyspepsia The client states, "I'm feeling a bit nervous today." Try different methods of oral care on unresponsive clients to see what works best. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. Sudden attacks of sleep This client can wait until the others are treated. A client with an above the knee amputation reporting phantom pain. 3. Notify the board of nursing (BON) that the float nurse is an alcoholic. Correct: The client has the right to be involved in the decision making of their care. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. 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. 1. A nurse is prioritizing care for two clients at the start of the shift. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. A goal for this client is to use proper body mechanics at all times. 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. The facility has insurance that will cover malpractice litigation Check environment for potential safety hazards. b. The nurse should use close-ended questions when assessing which of the following factors? Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Nurses Report Sheet Template Nicu. 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. 2. A charge nurse is observing a group of newly licensed nurses. a. Documentation is a communication tool for the interprofessional health care team. Everyone knows there are others who can chair this committee better than me The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. 4. c. 214 Send a day's worth of medications with the client to the receiving facility. A client post pacemaker insertion, awaiting discharge instructions. 1. c. Washes and rinses her hands for 10 seconds Photo comes from the Greek word for light. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. A nurse is planning care for a female client who has an indwelling urinary catheter. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. 3. c. Include intact skin at the wound edges in the culture Donning gloves and using a gauze pad to grasp and remove dentures d. Decreased calcium excretion, c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown), 27. d. Counting radial pulse 2. 3. a. b. Numbness These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. This would be out of the UAP's scope of practice. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? The nurse is focusing on which of the following elements of the communication process? 3. Which of the following actions should the nurse take regarding informed consent? Correct: If suspicious behavior occurs, it is important to keep careful, objective records. b. I'll rewrap my ankle starting from the knee down c. I suggest you talk with a mental health counselor about your concerns UAPs can assist with elimination and are taught how to measure output. Evaluate pain relief after narcotic administration. This includes medication enemas. a. Shakes the soiled linen to remove any toilet paper remnants The nurse asks why the client needs to know this. Correct: An LPN should be assigned clients with predictable outcomes. b. 2. 4. d. Remove tea and coffee from meal trays, b. A client receiving a blood transfusion that requires monitoring. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 5. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. 1. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. 1. Which of the following actions should the nurse perform when opening the sterile pack? b. The nurse should initiate a referral with which of the following members of the interprofessional health care team? 4. 4. So what is wrong with option #1? They are more direct when discussing issues Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. Dentures should be stored in a denture cup. Client who has multiple injuries from a motor vehicle accident. Suggest splitting the shift with another nurse. 1. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. b. a. Client prescribed antibiotics for cystitis. 4. Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Use double bagging to remove soiled linen from the client's room 2. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. Aplastic anemia is a rare but serious condition. 4. leadership management of care nurse on unit is providing care for group of clients. a. The nurse should call for immediate help so that a safe care environment is maintained for all clients. Correct: Communication is important in delegation, as is follow-up. b. 4. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. c. Hand-off technique We do not know the extent of her injuries based on what the option tells us. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. 2. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. 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. Select all that apply. Nursing questions and answers. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. Collecting I & O totals for unit clients at the end of shift. 1 (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. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. A client with COPD complaining of shortness of breath on exertion. 2. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department d. Highly concentrated urine, 91. c. Explain the risks and benefits of the procedure Most of the following sentences contain errors in the use of modifiers and comparisons. 2. The client attempted to climb over the side rails and fell 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. Which of the following responses should the nurse provide? A client receiving heparin injections for deep vein thrombosis. Removing the client's dentures 1., 2., 4., & 5. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. 5. A nurse is caring for a client who states, "I have got to get out of this hospital! c. Discard the tablet and obtain another dose of medication If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? 5. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. b. Donation costs are the responsibility of the donor's family and estate Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. c. Inform the surgical team to cancel the client's surgery Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Focus on the client's present circumstances instead of his personal stories 4. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. d. Mask, 83. d. Anger, b. Select all that apply c. The client's culture 2. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. d. What have you done in the past to cope with this issue? Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Convenience for the nursing staff or the client's family 1. Incorrect: This would unnecessarily alarm the clients. The best practice committee utilizes current research in their recommendations. b. 3. a. The area surrounding the insertion site feels warm to the touch Assessing this client and titrating the diltiazem requires the skills of an RN. Notify the primary healthcare provider of transfer completion. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. 3. b. Semi-formed stools are great news! Thoracentesis reporting shortness of breath. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. Which of the following actions should the nurse include in the plan? 1. A nurse is assessing a client who has narcolepsy. A nurse is teaching a client about carbon monoxide poisoning. 3. A nurse enters an older adult client's room to insert a saline lock. 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). Describe the types of machining operations that can be performed on a lathe. This client needs ongoing monitoring which is within the scope of practice for the LPN. 3. A nurse who is on hormone replacement therapy. (Select all that apply) A high concentration of carbon monoxide can cause death Cardiac catheterization with a decreased pedal pulse below insertion site. 5. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Question: A charge nurse is making client care assignments. Reach around the pack and open the top flap away from the body Refuse the delegated intervention. e. Dysuria, 49. c. When asking the client how he completes his ADLs Which of the following statements should the nurse identify as an indication the client needs further teaching? Pernicious Anemia Society The nurse should not lecture, scold or argue with the float nurse. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. a. Client scheduled for a dressing change to foot ulcer. c. The restraints should promote the client's safety and prevent injuries Place the client in a lateral position e. Throw rugs, 40. 3. a. a. 4. a. Auscultate breath should at least ever 2 hr Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion.