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Select all that apply. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. D. In order to reorganize staffing, the nurse manager should initiate which action first? This is a task that can be delegated to the LPN/LVN. Documentation of what occurred, and the client's assessment is required in the nurse's notes. Incorrect: The concern here is the client being fed their meal. A nurse is completing discharge teaching with a client. This service began with the client's admission to the hospital, 18. The nurse has just completed a 12 hour shift. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. 4. 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. Provide an adaptive feeding device for the client 4. 1. 2. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Fruity breath. Answer the following question to test your understanding of the preceding section: The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. c. I'll need to shave the hair off the skin where I place the electrodes The nurse is reviewing some clients' prescriptions. The nurse has been assigned four clients. Cardiac catheterization with a decreased pedal pulse below insertion site. 6. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. a. Broth Provides safe, effective delivery of patient care in . 4. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? Incorrect: Atrial fibrillation places the client at risk for blood clots. 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. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. _________________ (magnanimous), a. generous Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. 2. Explain administration is demanding a decreased overtime. 3. 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. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Assist a client to ambulate using a gait belt. The nurse has received the change-of-shift report. Remind the client to avoid tight fitting clothes. Which of the following actions should the nurse take to assist the client with feeding? 4. Reporting laboratory findings to a member of the client's family Who should the nurse see first? A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Nothing will get passed the complete blockage. b. Assess the client a. Administering 3 g/hr IV of morphine would be extremely dangerous. Evaluate client's safety risk factors. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. c. Face shield (SATA) -Bathing a client who had an amputation 2 days ago. c. Contact Point out inconsistences in the client's behavior b. Channel c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. A client requesting assistance packing his belongings for discharge later today.. 2. A nurse just back from maternity leave. Assist the float nurse with the clients case. Invite staff to contribute ideas on scheduling changes. Incorrect: Medications are not transferred with the client to a new facility. Allow families unlimited visitation around the clock to meet their schedules. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 4. 3. a. 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. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 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. A nurse is caring for an older client who is at risk for skin breakdown. 1. When the licensed person cannot determine this, the task should not be delegated. 3. Correct: The medical nurse can be assigned to this client. c. I will inspect my crutches everyday for signs of wear Which clients would be appropriate assignments for the LPN/LVN? This should not be delegated to the LPN/LVN. Autonomy vs shame and doubt 2. b. I will try to anticipate and avoid stressful situations when possible Provides day to day direction and supervision to assigned direct patient care staff. 3. Injuries from a motor-vehicle accident can be life threatening. c. Measurement of residual urine after urination An adult (18 years or older) can create an advanced directive. 2. 2. 1., 2., 3., & 4. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Place the client in low Fowler's position The nurse should do this when repositioning is needed. Select all that apply. a. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? A nurse is providing discharge teaching for a client who requires home oxygen therapy. a. 8. Which task should the nurse take responsibility for completing? a. The client was lying on the floor next to his bed 3. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. A client with diabetes admitted for debridement of a foot ulcer. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Nothing life threatening, but an assessment needs to be made regarding the ulcer. Initiative vs guilt Pick up the tray and tell the UAP that they didn't do a good job. c. I suggest you talk with a mental health counselor about your concerns Report of feeling pressure c. Document in the client's medical record that she completed an incident report Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. Remind the client to tell the nurse when he has to urinate 1. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. A client with a fractured right humerus who reports the cast is too tight. This is likely cholelithiasis, which will need to be checked out. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. What action should the nurse implement first to ensure client safety? 1. December 5, 2020. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Which of the following statements should the nurse identify as an indication that the client understands the instructions? 1. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). This could cause a medical emergency. 2. Nothing life threatening. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Which of the following statements should the nurse make? Notify the charge nurse of the observations. The nurse suggest that the family might need to respite care services. 4. Which of the following actions indicates that the AP understands the principles of infection control? The nurse should not lecture, scold or argue with the float nurse. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Client to receive dietary education. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. a. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day 4. The stem does not indicate any loss of neurological function resulting from the seizure activity. 1. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. b. 2. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. c. Paraphrasing b. d. Bend at the knees when picking up an object, 99. Select all that apply a. I'll sit with my knees lower than my hips b. I will call the doctor and get the prescription 5. 1., 2., & 5. A nurse is caring for a client who has a wound infection. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. The primary healthcare provider may have suggestions but this is not the best first action. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. This stage is when testing occurs to identify boundaries of interpersonal behaviors 4. Electric cords behind the furnitrure Client reporting a headache and has a fruity breath. One nurse lifting as the client pushes with his feet This individual should be provided appropriate comments of appreciation for this accomplishment. Which response by the LPN is appropriate in response to the inappropriate delegation? e. Dysuria, 49. Showing disapproval These are appropriate tasks for an UAP to complete. e. The urge to move the legs when trying to sleep, 66. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Speak using his usual tone of voice 4. This is an appropriate and safe action for the unlicensed nursing assistant to do. A charge nurse is making client care assignments. b. A nurse receives a client care assignment from the charge nurse that he believes is unfair. (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. 2. a. I will wear gloves when removing food from the freezer UAPs can assist with elimination and are taught how to measure output. c. I'll clean the inside of the container with a wipe a.) Assign a nursing assistant to help the client with self-care activities. c. Palpating for pedal edema This client is at a high risk of infection. 2. Speak to the UAP to determine what happened with the feeding. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? c. Notifying the provider of physical exam findings Witness the client's signature 4., & 5. 3. 1. Which of the following actions is an example of a violation of confidentiality? 3. 2. c. Consensus evolves in this stage A client requesting assistance packing his belongings for discharge later today., Pain d. Motor impairment, 84. 3. 208 1. Wrapping the dentures in tissue while the client sleeps a. I wish I didn't have to attach the electrodes to my skin d. Lean back in the chair, b. 1. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Placing the traction weights on the bed to transfer the client to x-ray. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. which client would be an appropriate care assignment for this lpn? 3. Report the incident to the charge nurse Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. b. Nurses Report Sheet Template Nicu. a. Which preoperative prescription should the nurse question? Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Nothing by mouth (NPO). (Select all that apply.). 4. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Which of the following interventions should the nurse include? Tenderness over the symphysis pubis 3. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Notify the primary healthcare provider of transfer completion. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Limit the client's fluid intake in the evening A client receiving a blood transfusion that requires monitoring. 2. 3. c. Use an aggressive tone of voice Which of the following actions should this nurse take? The nurse does not know the skills of the new UAP. b. What task would be best to assign to the LPN/LVN? b. Female client stating she has been raped. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. Could you try contacting a support group Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. A client with fibromyalgia reporting generalized pain of 7 out of 10. The client is apparently stable and does not require any advanced assessment skills or specialized care. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. a. Bathe a client who had an amputation 2 days ago a. Auscultating heart sounds d. Highly concentrated urine, 91. Narrative interaction b. Negligence Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Which of the following actions should the nurse take regarding informed consent? b. I'll rewrap my ankle starting from the knee down The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. 3. Remind the client that a signed informed consent form is a legally binding document Bargaining d. Custard c. There is fluid leaking around the insertion site b. 4. 4. a. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Which group of clients should she assign to the medical surgical nurse? & 5. }? benefactor of the world. Decreased or suppressed respiration are priority.