a. A nurse is orienting a new assistive personal (AP) to the unit. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. c. Behaving defensively Reach around the pack and open the top flap away from the body, 53. and 16 g of fat. Only the state Board of Nursing can legally determine the LPN's scope of practice. Left upper forearm b. I'm so sorry to hear about this Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. c. I'll bear weight on my ankle for 10 minutes every hour 3. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Relax her abdominal muscles when she lifts an object Complete a client assignment sheet for the oncoming staff. b. e. Feed a client who had a stroke 3 months ago, 31. 6. Which of the following instructions should the nurse include? The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. This referral would be appropriate. 4. 5. c. Holds the soiled linen against her body while carrying it to the linen bag 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. Notify the primary healthcare provider of transfer completion. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Start MgSO4 at 3g/hr IV Which of the following pieces of PPE should the nurse remove first? 1. A nurse is preparing to obtain a blood specimen from a client by venipuncture. c. Explore the client's feelings about dietary modifications The charge nurse is making client assignments for a neuro-medical floor. c. Gender 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. 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. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Correct. Refuse the delegated intervention. 3. They have found my address and are coming for my family!" Client with a T-5 spinal cord injury beginning rehabilitation therapy. 1. 3. Which clients would be appropriate assignments for the LPN/LVN? c. Discard the tablet and obtain another dose of medication 2. Correct: Communication is important in delegation, as is follow-up. 5. 1. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Elderly clients have special fluid and electrolyte issues after a fall. A nurse is caring for a client who has a wound infection. A nurse is developing a plan of care for a client who practices Islam. A nurse is preparing a sterile field. e. Feed a client who had a stroke 3 months ago, 32. The RN with 2 weeks' experience on the postpartum unit. 3. Which task should the nurse take responsibility for completing? b. Wash the tablet off with alcohol and place it in a clean medicine cup 1. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. Select all that apply 1, 3 & 5. What is the best care assignment for this client? 1., 2., 3., & 4. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. c. Blood-tinged urine d. Determine if the client uses hearing aids, b. Initiate oxygen and IV lines as needed. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Dentures should be stored in a denture cup. Include any relevant statements the client made about the ulcer, 64. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? In the following sentences, circle each incorrectly used lowercase letter. 4. 5. b. As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Ask the charge nurse to evaluate the intervention. 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. 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. Which client should the nurse assess first? 4. Discuss the competency of the surgeon a. Bathtub with rails c. I will make sure my visitors smoke outside 3. Report the incident to the charge nurse This task cannot be delegated to the LPN/LVN. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. Incorrect: The RN is responsible for assessment and evaluation of clients. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Clients over the age of 65 must have a saline lock according to facility policy 1. Aplastic anemia is a rare but serious condition. 1. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. Incorrect: The charge nurse does not have to assess every client. 3. 1. Explain administration is demanding a decreased overtime. A nurse is caring for a client who is immobile. UAPs can assist with elimination and are taught how to measure output. Select all that apply Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. 4. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 2. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. A nurse is admitting a client from a long-term care facility. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Which task would be appropriate for the nurse to assign to an LPN/VN? Which of the following is the priority action by the nurse? d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. d. Providing information, a. Correct: The client may be experiencing a myocardial infarction and requires further assessment. 1. leadership management of care nurse on unit is providing care for group of clients. Draining the colostomy bag on a client with diarrhea. 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. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). a. A high concentration of carbon monoxide can cause death (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 2., 3. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. "The client is weak on the right side, so please assist the client with dressing . Collecting I & O totals for unit clients at the end of shift. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. c. Inform the surgical team to cancel the client's surgery Which of the following actions should the nurse take? (Select all that apply) 3. d. Bend at the knees when picking up an object, 99. c. Contact Semi-formed stools are great news! The client is getting better. 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. Compartment syndrome could be developing which can impede circulation and cause nerve damage. Incorrect: The nurse is responsible for monitoring a client. 1. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Report of feeling pressure The nurse suggest that the family might need to respite care services. d. Left forearm, b. a. Reposition the client every 3 hr 2. Which of the following actions should the nurse take? d. What have you done in the past to cope with this issue? 2. The client with cystitis is stable and has a predictable outcome. Remind the client that a signed informed consent form is a legally binding document 1. 1. 2. Channel 5. 1. The facility has insurance that will cover malpractice litigation 2. Removing the abdominal dressing 2. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. one of the licensed practical nurses Get the answers you need, now! Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. c. Assist the client to the floor and begin mouth-to-mouth Which of the following actions should this nurse take? b. Negligence Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. a. c. Palpating for pedal edema Correct. c. Review the client's progress toward personal objectives 3. 2) Assist a client to ambulate using a gait belt. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Correct: An LPN should be assigned clients with predictable outcomes. Which of the following tasks should the nurse delegate to assistive personnel (AP)? 4. We see that the temperature is already elevated, which makes us worry that infection is present. b. 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. a.) The nurse should perform which of the following activities in this space? Phone report to the receiving nurse. Ask the client to perform a return demonstration of insulin injection The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. A nurse is caring for a client whose partner asks to speak with the nurse. c. Washes and rinses her hands for 10 seconds, 11. Incorrect: Atrial fibrillation places the client at risk for blood clots. Showing disapproval A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 1. _________________ (magnanimous), a. generous You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. In what order should the nurse see the clients? Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Review a low-sodium diet for a client who has hypertension. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Client eating a simple-carb snack due to weakness. This would be an acceptable task to assign to the UAP. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. Ask the primary healthcare provider to suggest the best oral care procedure. c. imaginary A charge nurse is observing a group of newly licensed nurses. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. A nurse is caring for a client who is postoperative following an appendectomy. Increased insulin production c. The nurse may serve as a witness to informed consent for organ donation A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. The client post PEG placement is stable. Which of the following statements should the nurse identify as an indication that the client requires further clarification? Limit the client's fluid intake in the evening a. 1. 4. Lumbar puncture reporting a headache. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Speak to the UAP first and then decide if a between meal supplement is needed. A nurse is planning care for a female client who has an indwelling urinary catheter. A nurse receives a client care assignment from the charge nurse that he believes is unfair. 3. Identify and assess each incoming client. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. The LPN can monitor the wound and provide care to the PEG insertion site. 1. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a A nurse is caring for a client who states, "I have got to get out of this hospital! A nurse enters an older adult client's room to insert a saline lock. Drag and Drop the items from one box to the other. c. Offer the client personal thoughts and beliefs The option does not say the client is terminal, in a vegetative state, or in a coma. The client receives home health care and spends most of his day in a reclining chair. 4. d. Do you think crying will help? A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Pain d. Lean back in the chair, b. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. d. Perception (Select all that apply.). 3. Correct: The UAP can remind the client to do something that has already been taught by the nurse. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. 4. Notify the surgeon that the client wishes to withdraw informed consent for the procedure Determining the client's length of stay 1. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Which of the following items should the nurse offer the client? Which of the following responses should the nurse make? a. I'll provide more stimulation in his environment 1. A goal for this client is to use proper body mechanics at all times. Each ROM movement should be repeated 5 times during the session. d. principal. b. I will begin once the client's discharge order is written a. 3. Ask client if they are eating small, frequent meals. Teaching insulin self administration cannot be delegated to the LPN. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Client reporting epigastric pain and nausea after eating. Assist a client to ambulate using a gait belt Client with chronic emphysema experiencing mild shortness of breath. Did you think dehydration and fluid volume deficit? Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. d. Highly concentrated urine, 91. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44.
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