c. Offering false reassurance 3. 6. Discuss the issue with the leader of the "best practices" committee. e. an open perineal wound, 92. b. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? Client with cast to right leg requiring pain medication. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 4. c. Use intermittent eye contact d. Place the tablet directly into a medication cup, 36. 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. The women's health charge nurse is making assignments for the next shift. Limit the client's fluid intake in the evening 1. What is the best response by the charge nurse? Client to receive dietary education. A client requesting assistance packing his belongings for discharge later today., Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. Following the teaching, the nurse asks the client to describe one physical effect. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? c. Do not eat or drink anything the morning of the test Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. b. Assigning tasks to an AP This client needs careful monitoring and specialized care. A float nurse arrives on the unit to assist in the care of clients for the shift. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. e. Feed a client who had a stroke 3 months ago, 32. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Which response by the LPN is appropriate in response to the inappropriate delegation? A school-aged child with a fractured femur who is in balanced suspension traction. The client receives home health care and spends most of his day in a reclining chair. b. b. Checking capillary refill beneath the client's fingernail There may be a good reason that the tray was not served. 3. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. c. Inflate the balloon when the urine flow stops c. Rephrase statements the client does not hear 2. No! c. I will begin upon the client's admission to the facility These are appropriate tasks for an UAP to complete. a. This schedule may leave some clients too exhausted to visit with family. In which situation should the nurse consult the client's advanced directive? The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. This referral would be appropriate. If the client is unstable, the nurse would retain the role of measuring the vital signs. The nurse is planning care for a client admitted with Alzheimer's Disease. Nothing life threatening. d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. b. Twist at the waist when she moves an object to one side Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Protective Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Which referral would most likely be appropriate for the nurse to make? b. To confirm the placement of the NG tube If a sentence is already correct, write CCC. A list of current medications is sent to the facility. c. I will complete the smoking cessation program I started b. I can detect the presence of carbon monoxide by a metallic odor Select all that apply. Teach the UAP to change surgical dressings. 4. Explain administration is demanding a decreased overtime. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? Provide an adaptive feeding device for the client Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. It is quicker to administer medications intravenously in the hospital a. He charge nurse is making client care assignments for the evening shift. The nurse asks why the client needs to know this. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? Most of the following sentences contain errors in the use of modifiers and comparisons. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. 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. In what order should the nurse see the clients? Did you recognize ureterolithiasis as "kidney stones"? Charge nurses have integral roles in healthcare organizations. Which of the following actions by the nurse is considered an indirect nursing care activity? a. Report of feeling pressure Which of the following info should the nurse include? 3. Which of the following pieces of PPE should the nurse remove first? Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). 2. Could you try contacting a support group This service began with the client's admission to the hospital, 18. The charge nurse is planning the staff assignments for the clients on a neurological unit. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Who should the nurse see first? Which action should the nurse interrupt the UAP from performing? Reach around the pack and open the top flap away from the body The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. c. Visual observation for nonverbal signs of pain 2. This action is a defensive intervention, and does not address the quarrelsome behavior. b. What task would be best to assign to the LPN/LVN? A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. 4. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. c. Decreased sodium excretion The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Teaching insulin self administration to a diabetic client. Which of the following actions should the nurse take? a. I'll provide more stimulation in his environment b. Which of the following infection-control precautions should the nurse use caring for this client? 5. 2. a. Shakes the soiled linen to remove any toilet paper remnants 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. 4. a. Encourage the client to be more cooperative. 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? Photo comes from the Greek word for light. What action should the nurse implement first to ensure client safety? They are likely to wait for others to initiate conversation In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. 2. 4. b. I will come back later and we can talk 3. Encourage the client to use self-exploration There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? a. The surgeon initially prescribes a clear liquid diet. b. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? 3. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Evaluate pain relief after narcotic administration. 4. d. Establishing the client's secondary medical diagnoses, b. 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. Invite staff to contribute ideas on scheduling changes. Did you think dehydration and fluid volume deficit? Relief of urinary retention Which of the following actions should the nurse take? Assign a nursing assistant to help the client with self-care activities. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. Which of the following client statements indicates an understanding of the procedure? 1., 4., & 5. 4. The nurse is focusing on which of the following elements of the communication process? Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? 1. Observe the client before taking further actions Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. Besides, a charge nurse is a leader on the floor and should possess . A nurse instructs a female client about collecting a midstream urine sample. 3. It can result in muscle spasm and tissue damage. 1. 1. B. c. They tend to use more verbal communication 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. Client reporting a headache and has a fruity breath. Refuse the delegated intervention. A lack of rapid eye movement (REM) sleep c. Request a tray without pork Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. a. Which clients should be assigned to the CNA? b. b. The nurse should do this when repositioning is needed. Call the client's provider The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. The nurse should not lecture, scold or argue with the float nurse. a. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Report of feeling pressure c. Hallucinations at the onset of sleep Prior to shift report, the charge nurse is making assignments for the nurses on the shift. b. b. In order to reorganize staffing, the nurse manager should initiate which action first? The body needs vitamin B12 to make red blood cells. 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). Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a a. I will begin 48 hr before the client's discharge 6. 2. 2. 1. A nurse is orienting a new assistive personal (AP) to the unit. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Call the family of a client suffering from dementia to discuss long term care placement. c. Confrontation c. Take the client to the bathroom every 2 hr 1., 2., 4., & 5. 3. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. b. Richied5864 Richied5864 . Incorrect: The nurse cannot assign teaching to the UAP. An increased temperature will have a direct effect on the brain's metabolism and function. a. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. The client with cystitis is stable and has a predictable outcome. The nurse considers various ideas submitted by team members. Incorrect: Moistening the dentures will ease insertion. b. Select all that apply. Briefly assess every client. 2. Assigning blame for the changes to administration will not help staff adjust. What client should the nurse assess first? The client's self-report of pain severity 1. 1., 2., 3., & 4. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Which of the following actions should the nurse take to assist the client with feeding? 1. A nurse is assessing a client who is experiencing prostatic hypertrophy. The area surrounding the insertion site feels warm to the touch, 61. Witness the client's signature Symbolic communication Which of the following activities should the nurse perform in this zone? d. Do you think crying will help? A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Well, do you see the q.d.? d. Wait to discuss the behavior in the presence of others, a. Anyone over age 18 can have an Advanced directive. 1., 2., 4., & 5. Which of the following types of communication breakdown does this response represent? What was the hint? Thoracentesis reporting shortness of breath. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Notify the board of nursing (BON) that the float nurse is an alcoholic. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 3. c. Face shield Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29. The nurse has received the change-of-shift report. Obtain a client's consent Wears a gown when entering the room of a client who requires contact precautions Review a low-sodium diet for a client with hypertension. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. Focus on the client's present circumstances instead of his personal stories A nurse is caring for an older client who is at risk for skin breakdown. c. Review the client's progress toward personal objectives d. Water heater temp 54.4 C (130 F) 4. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Speak to the UAP to determine what happened with the feeding. Incorrect: This again is assessment which is the role of the RN only. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Administering 3 g/hr IV of morphine would be extremely dangerous. Teaching insulin self administration cannot be delegated to the LPN. a. Elderly client admitted 30 minutes ago with reports of constipation for four days. 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. These individuals are selected by the charge nurse, and do not have to be nurses. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. c. I will inspect my crutches everyday for signs of wear 4. b. a. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). 1. 4. 3. 4. a. What interventions can the nurse delegate to the LPN/VN? The LPN can monitor the wound and provide care to the PEG insertion site. The client is reporting anxiety, discomfort, and a feeling of bloating. 3. Currently, your census is 11, with one empty bed. 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. Rewrite each incorrect sentence to correct the error. Include any relevant statements the client made about the ulcer, 64. The client then states, "I have changed my mind and do not want to have the procedure done." Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. 1., 2., & 5. A client with an above the knee amputation reporting phantom pain. a. The expected standard of care was strict bed rest), 96. a. Pernicious Anemia Society Incorrect: It is out of the UAP's scope of practice to administer medication. Which of the following tasks should the nurse delegate to AP? Moistening the dentures prior to inserting them b. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago b. 3. A charge nurse is making client care assignments. Provide a between meal supplement to the client. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. A nurse asks a client how he is feeling. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. c. Behaving defensively Gather supplies to prepare room for isolation. Make nursing assignments appropriate to the skill level . 4. b. Ask for any staff objections to rearranging work hours. 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. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. a. -Review a low-sodium diet for a client who has HTN 4. Try different methods of oral care on unresponsive clients to see what works best. Which of the following actions should the nurse include in the plan? c. There is fluid leaking around the insertion site A client who is disoriented and awaiting transfer to a long-term care facility. When asking the client about his receptiveness to the transfer 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. What is the appropriate assignment? A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. However, it remains true pain for this client and the client would need intervention to help manage this pain. The nurse should use close-ended questions when assessing which of the following factors? The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. 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. 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.