A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Handoff and Nursing Report Sheet. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which of the following statements should the nurse identify as an indication that the client needs further instruction? 2. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Try different methods of oral care on unresponsive clients to see what works best. This service focuses on teaching the primary caregiver to meet the client's needs Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. A client receiving a blood transfusion that requires monitoring. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. a. The charge nurse should notify the nursing supervisor who will seek additional staff. A float nurse arrives on the unit to assist in the care of clients for the shift. (Select all that apply.) A nurse is implementing direct nursing care for a group of clients in an acute care facility. 1. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). d. Do you think crying will help? Observe the client before taking further actions 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. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. The nurse should not be assigned to provide care if impairment is suspected. Assist a client to ambulate using a gait belt Correct: Hot water may damage dentures so intervention is needed. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. 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). CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. It also helps the client deal with issues that are important to him), 19. Richied5864 Richied5864 . 4. 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 should the nurse include as a criterion for applying restraints? Which client can be assigned to the LPN? What interventions can the nurse delegate to the LPN/VN? Decide which choice fits best in the blank. Suggest splitting the shift with another nurse. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. The nurse could definitely be part of the committee. The client should be assessed first to rule out respiratory difficulty and hemorrhage. Fundamentals Practice Flashcards | Quizlet Select all that apply. b. This stage involves constructive efforts on the part of the group members Change the subject when the client behaves defiantly A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. 4. d. Talk with the client's partner, b. 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. b. b. Wash the tablet off with alcohol and place it in a clean medicine cup 3. Irrigate a client's ear canal. 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. Serve food that have a hot/cold balance The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. b. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. A nurse is administering a cold therapy application to a client. 2. c. Include intact skin at the wound edges in the culture a. c. Confrontation a. Gloves Schedule visiting times in two-hour increments so clients are not overwhelmed. Which of the following client statements indicates an understanding of the procedure? The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Encourage clients and families to develop mutually appropriate visitation times. A high concentration of carbon monoxide can cause death However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Which prescription should the nurse question and have corrected? 2. 2. Therefore, this would not be the most appropriate nurse to assign to this client. a. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? a. Perform range of motion (ROM) exercises at least 2-3 times daily 2. The client says, "go away, no one can help me." Which task would be appropriate for the nurse to assign to an LPN/VN? Pernicious Anemia Society A charge nurse is making client care assignments. There are a total of 10 adult clients. There may be a good reason that the tray was not served. 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. a. Elicit info from the client a. 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. Drag and Drop the items from one box to the other. This stage is when testing occurs to identify boundaries of interpersonal behaviors 3. a. 1. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. c. Visual observation for nonverbal signs of pain Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. A nurse is admitting a client who has a partial hearing loss. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. A charge nurse is making client care assignments. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. c. I will cover the catheter so he cannot see it c. 214 Thus, the tasks involve successful management of the charge nurse's responsibilities. A nurse just back from maternity leave. Correct: Did you notice the hint? Solved 4. A charge nurse is making client care assignments. | Chegg.com Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. a. Battery The charge nurse's best response is to first obtain the needed information to make the best decision. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. In what order should the emergency department triage nurse send these clients to a room for treatment? Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. 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. Turn on local news for up-to-date information on the train derailment. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Reach around the pack and open the top flap away from the body, 53. Remember airway, breathing and circulation (ABCs). Describe the types of machining operations that can be performed on a lathe. c. Environment b. I'm so sorry to hear about this Serve milk products separately from meals c. Gender Incorrect: This group of clients needs specific teaching. Gown Client scheduled for a dressing change to foot ulcer. 3. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. Select all that apply What task would be best to assign to the LPN/LVN? b. Urinary frequency for several days d. When asking if the client took his medications this morning, 82. The nurse voices his concern to the charge nurse. Which of the following actions should the nurse take to assist the client with feeding? Which referral would most likely be appropriate for the nurse to make? a. The client post PEG placement is stable. A nurse is caring for a client who has emphysema and has difficulty with mobility. c. Palpating for pedal edema d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago a. The client is reporting anxiety, discomfort, and a feeling of bloating. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound a. Bathe a client who had an amputation 2 days ago 2. Client scheduled for breast reconstruction after mastectomy. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain 3. with this question, the nurse is using which of the following communication techniques? A two-hour limit on visits discourages quality time. 1. Which client should the nurse assess first? A nurse is developing a plan of care for a client who practices Islam. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Assist client to brush and floss teeth. Obtain a client's consent Left upper forearm Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? A charge nurse is making client care assignments for the day. which The RN with 8 years' experience in the Intensive Care Unit. 4. Which of the following findings indicates that the client is meeting this goal? 1. a. The nurse prefers to check all vital signs on all clients. 4. Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. Which of the following indications should the nurse include? UAPs can assist with elimination and are taught how to measure output. 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. Select all that apply e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. Providing a passive response c. Hallucinations at the onset of sleep, 65. The best practice committee works to improve clinical practice based on current research. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Only a plain enema or soap enema can be given by the UAP. b. The client was lying on the floor next to his bed 5. Determine caregiver's stress level and coping strategies. A nurse is caring for a client in the orientation phase of the nurse-client relationship. c. Depression This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. 2. The client reports constipation for 4 days which may be an indication of worse problems. What is the best first action for the nurse to take in order to achieve this goal? The spouse can rescind the Advance Directive if the client becomes unresponsive. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 5. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. The charge nurse needs additional information to make a decision. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. Licenced practical nurses are a little less educated than registered nurses. 5. 1. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Plan all care to be completed in early morning to allow afternoon for visitation. 1. 3. The third client would be the one needing a dressing change. Send a day's worth of medications with the client to the receiving facility. The charge nurse is making client assignments for a neuro-medical floor. b. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. What action should the nurse implement first to ensure client safety? Determine which personnel could be sent to the command center. Which of the following interventions should the nurse include? A nurse is planning care for a female client who has an indwelling urinary catheter. a. 212 which client would be an appropriate care assignment for this lpn? 5. c. I will place an area rug at the entry of my bathroom a. The nurse caring for the client at the time of death requests organ donation It would not be appropriate to overload this new employee with extra work. Which of the following tasks should the nurse delegate to assistive personnel (AP)? 4. An adult (18 years or older) can create an advanced directive. Each ROM movement should be repeated 5 times during the session. Which group of clients should she assign to the medical surgical nurse? 1. A nurse is working with an assistive personnel (AP) to 55. Assist a client to ambulate using a gait belt. Cardiac catheterization with a decreased pedal pulse below insertion site. Discuss the issue with the leader of the "best practices" committee. b. Pick up the tray and tell the UAP that they didn't do a good job. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Which of the following actions is the priority for the nurse to include in the client's plan of care? d. Perception What is the major histological difference between thick and thin skin? b. I will bear the weight of my body on my hands 4. The nurse considers various ideas submitted by team members. Injuries from a motor-vehicle accident can be life threatening. c. Washes and rinses her hands for 10 seconds, 11. c. I'll clean the inside of the container with a wipe The body needs vitamin B12 to make red blood cells. 4. Currently, your census is 11, with one empty bed. In which situation should the nurse consult the client's advanced directive? Alert all off-duty personnel to stand by in case of call- in. The nurse who made the medication error should take which of the following actions first? This would be out of the UAP's scope of practice. 1. Incorrect: The nurse retains the responsibility for the delegated task. Nothing life threatening. A nurse is having difficulty caring for a client due to variables affecting the communication process. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. A person can be designated to make medical decision in the event the client cannot. 5. c. Use an aggressive tone of voice The other options may be correct but are not the best first action. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. A cardiac step down unit has requested float staff because of multiple impending admissions. b. Flashcards - chapter 7 - FreezingBlue They are more direct when discussing issues Determining the client's length of stay NUR 212 Patient assignments.docx - M2.4: Making Client Care 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. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 2. This is an appropriate prescription. Places the soiled linen in the floor before bagging it The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. The nurse is planning care for a client admitted with Alzheimer's Disease. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. b. I will try to anticipate and avoid stressful situations when possible b. 3. *HURST REVIEW Qbank/Customize Quiz - Manageme, *HURST REVIEW Qbank/Customize Quiz - Adult He, *HURST REVIEW Qbank/Customize Quiz - Basic Ca, *HURST REVIEW Qbank/Customize Quiz - Fundamen, ***HURST REVIEW NCLEX-RN Readiness Exam 1***, The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Edge Reading, Writing and Language: Level C, David W. Moore, Deborah Short, Michael W. Smith. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. A nurse asks a client to share personal stories. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Write the letter of your choice on the answer line. Administering IV pain medication to a two day post op client. 3. 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. This client will also need a lot of education regarding anti-rejection medications. Provide an adaptive feeding device for the client Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). one of the licensed practical nurses Get the answers you need, now! Ask the float nurse, "Have you been drinking?" The primary healthcare provider may have suggestions but this is not the best first action. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Receive report from the emergency department (ED) on a new client. d. Discussing intake and output 1. 3. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Channel 2. What options would be appropriate for the nurse to take? 4. A home health nurse is conducting a home safety assessment for an older adult client. What task would be best to assign to the LPN/LVN? 3. The RN with 2 weeks' experience on the postpartum unit. 2. c. Changing a dressing A charge nurse is planning client activities for the day. Drag and Drop the items from one box to the other. a. a. d. Social conversation, a. 1. This would be out of the UAP's scope of practice. Which of the following actions by the nurse is considered an indirect nursing care activity? a. a. c. Irrigating a client's abdominal wound So, now you must decide which of these high priority clients should be seen in what order. A client with atrial fibrillation currently on a diltiazem drip. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. c. Inform the surgical team to cancel the client's surgery Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 4. It is quicker to administer medications intravenously in the hospital Twist at the waist when she moves an object to one side 6. A charge nurse is making client care assignments. c. Paraphrasing These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. b. An experienced person who can research "best practice" regarding the issue is needed. A Charge Nurse Role: The Ultimate Guide. Client with chronic emphysema experiencing mild shortness of breath.
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