This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. 1. When determining if the client is eating a well-balanced diet Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. It would not be appropriate to overload this new employee with extra work. 5. 2. with this question, the nurse is using which of the following communication techniques? Besides yourself, there are the following staff: Your unit has 12 beds. 5. 2. Semi-formed stools are great news! Disconnect client's nasogastric (NG) tube suction to allow ambulation. c. Complete an incident report Four clients arrive for their appointment at a diabetic clinic. A charge nurse is making client care assignments for the day. which Incorrect: The nurse retains the responsibility for the delegated task. Which prescription should the nurse question and have corrected? Besides yourself, there are the following staff: Your unit has 12 beds. e. Feed a client who had a stroke 3 months ago, 32. Allow the UAP to work without supervision. Accept assignment, documenting personal concerns regarding work conditions. The best practice committee works to improve clinical practice based on current research. a. Auscultating heart sounds c. Raised toilet seats A nurse is caring for a client who frequently attempts to remove his IV catheter. the nurse responds, "don't worry, no one will harm your family." Feedback 2) Assist a client to ambulate using a gait belt. Assist a client to ambulate using a gait belt. c. We administer all medications intravenously to clients in this unit A nurse is caring for a client within the intimate zone of the client's personal space. 2. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. A nurse is teaching a client about the physical effects of chemotherapy. For which of the following tasks should the nurse wear protective eye equipment. c. Holds the soiled linen against her body while carrying it to the linen bag Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. 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. Fruity breath. (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 2. 4. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. 55. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). 2. b. Massage any bony prominences to promote circulation Battery Incorrect: This again is assessment which is the role of the RN only. This should not be delegated to the LPN/LVN. Client scheduled for a dressing change to foot ulcer. Incorrect: This client does not have a predictable outcome. Answer the following question to test your understanding of the preceding section: a. Which of the following statements should the nurse identify as an indication that the client understands the instructions? Drag and Drop the items from one box to the other. c. Gender A nurse is preparing to obtain a blood specimen from a client by venipuncture. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. d. Complete an incident report, 70. This would be out of the UAP's scope of practice. Complete a client assignment sheet for the oncoming staff. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. I'll apply ankle to my ankle today and tomorrow 2. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. b. Incorrect: Atrial fibrillation places the client at risk for blood clots. The charge nurse on the postpartum unit is making assignments. a charge nurse is making client care assignments for the day. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Monitor for GI upset 30 minutes after meals. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. Female client stating she has been raped. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Notify the board of nursing (BON) that the float nurse is an alcoholic. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. b. The supervisor can only send one LPN/LVN to the floor. 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. 4. 4. Sudden attacks of sleep c. I suggest you talk with a mental health counselor about your concerns 2. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. A nurse is caring for a client who expresses anxiety about his impending surgery. However, there are some basic points which are standard among all facilities. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. 2. 5. Which of the following findings associated with urinary retention should the nurse expect? The client was lying on the floor next to his bed (nurse should document what they actually see), 68. 2. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Hearing loss 6. 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. The client was lying on the floor next to his bed a. 3. A nurse is caring for an older client who is at risk for skin breakdown. 4. Which of the following actions should this nurse take? The surgeon initially prescribes a clear liquid diet. Electric cords behind the furnitrure Which of the following sites should the nurse plan to use to obtain the blood specimen? 2. Evaluate pain relief after narcotic administration. Symbolic communication 1. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. Right forearm Which of the following statements should the nurse identify as an indication that the client understands the discharge information? Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. d. Reduced blood viscosity, a. Auscultating heart sounds Incorrect: This client is exhibiting early signs of increased intracranial pressure. c. Depression d. Highly concentrated urine, 91. The client is considered unstable until assessed by the nurse. A nurse enters an older adult client's room to insert a saline lock. Which actions should be instituted by each unit's charge nurse? 3. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. Ask the RN why the assignment is too heavy. c. Changing a dressing Hanging a new bag of total parenteral nutrition (TPN). The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. What is the best care assignment for this client? 1. a. 5. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? c. Review a low-sodium diet for the client who has hypertension The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. c. Leave a nightlight on in the client's room Notify the primary healthcare provider. e. Talking with the client's partner, 79. d. Place the tablet directly into a medication cup, 36. Teaching about a medication Report the incident to the charge nurse The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 1. 1., 2., 3., & 4. a. b. 4. Encourage the client to be more cooperative. b. A nurse asks a client to share personal stories. Incorrect: Medications are not transferred with the client to a new facility. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Notify the nursing supervisor of the situation. An adult (18 years or older) can create an advanced directive. Remember, pick the killer answer first! This is an appropriate prescription. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. 3. Determine which personnel could be sent to the command center. b. Assigning tasks to an AP c. I'll need to shave the hair off the skin where I place the electrodes Which of the following tasks should the charge nurse reassign to a licensed nurse? This service began with the client's admission to the hospital Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). 4. A charge nurse is making client care assignments. Which of the following RNs should not be assigned to this baby? Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. 1 c. Offer the client personal thoughts and beliefs c. Paraphrasing b. he charge nurse is making client care assignments for the evening shift 4. Did you think dehydration and fluid volume deficit? The nurse cannot allow the UAP to perform advanced tasks. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? A nurse caring for a client is using active listening skills. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. A nurse is caring for a client who has emphysema and has difficulty with mobility. 77. Which action by an unlicensed nursing assistant would require the nurse to intervene? Risperidone .5 mg PO daily c. I'll bear weight on my ankle for 10 minutes every hour a. The situation should be explored before bringing the supervisor in on the situation. A nurse is caring for a client who is postoperative following an appendectomy. Which action should the nurse interrupt the UAP from performing? 4. d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. Of my three brothers and sisters, my sister Giselle has the best sense of humor. a. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. 5. This is a task that can be delegated to the LPN/LVN. 4. 4. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. This is an elderly client who is a new admit. (Select all that apply.). Monitor for behavioral changes. 2. a. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? a. I will wear gloves when removing food from the freezer Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Which of the following actions should the nurse take? This individual should be provided appropriate comments of appreciation for this accomplishment. 1. c. I'll wear low heeled shoes from now on 1. What task would be best to assign to the LPN/LVN? Have another nurse finish preparing the medications b. Wash the tablet off with alcohol and place it in a clean medicine cup 2. Speak to the UAP first and then decide if a between meal supplement is needed. b. Donation costs are the responsibility of the donor's family and estate (Select all that apply.). Review a low-sodium diet for a client with hypertension. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. 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. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. Which of the following findings indicates that the client is meeting this goal?
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