Which of the following should the nurse include as a criterion for applying restraints? Incorrect: This client is exhibiting early signs of increased intracranial pressure. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. A nurse is filling out an incident report after finding a client lying on the floor. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 1. Pain Providing a passive response However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. 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. c. The restraints should promote the client's safety and prevent injuries Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 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. 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. The RN with 10 years' experience pulled from the ER. Incorrect: The nurse retains the responsibility for the delegated task. The client must understand the need for restraints A post-cardiac catheterization needing assistance with bedpan. Witness the client's signature Which task would be appropriate for the nurse to assign to an LPN/VN? Give magnesium citrate 296 mL at 3 PM today. 4. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. A charge nurse is making client care assignments. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. b. I will begin once the client's discharge order is written When the licensed person cannot determine this, the task should not be delegated. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. 4. 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. 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. A nurse is caring for a client who expresses anxiety about his impending surgery. This is an elderly client who is a new admit. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Which of the following actions should the nurse take? Return any fresh linen not used for a client to the linen supply area a. Asking for an explanation Incorrect: The RN is responsible for collecting data. The nurse should initiate a referral with which of the following members of the interprofessional health care team? 1. 3. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Which of the following actions is the priority for the nurse to include in the client's plan of care? The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Speak to the UAP first and then decide if a between meal supplement is needed. Select all that apply. d. Remove and reinsert the NG tube, a. Place the client in low Fowler's position Anyone over age 18 can have an Advanced directive. It also helps the client deal with issues that are important to him), 19. a. 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. d. Perception Photo comes from the Greek word for light. A nurse who is 10 weeks pregnant. A client who is disoriented and awaiting transfer to a long-term care facility. 3. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. a. I will wear gloves when removing food from the freezer Administering 3 g/hr IV of morphine would be extremely dangerous. b. I will try to anticipate and avoid stressful situations when possible Assign more daily tasks to the UAP. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. There will likely be both physical and emotional injury that needs attention, which places this client third. It's unfortunate that I have to be in the hospital for this treatment Plan all care to be completed in early morning to allow afternoon for visitation. 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. Correct. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Incorrect: The concern here is the client being fed their meal. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. one of the licensed practical nurses Get the answers you need, now! A nurse is preparing medication for a client when another client has an emergency. Which of the following statements should the nurse identify as an indication that the client requires further clarification? Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen A charge nurse is planning client activities for the day. b. a. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) The client with chronic emphysema has expected shortness of breath. This includes medication enemas. C. Review a low-sodium diet for a client who has hypertension. c. Consensus evolves in this stage 4. b. The nurse is responsible for the assessment of all vital signs of post-op clients. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. Currently, your census is 11, with one empty bed. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Assist a client to ambulate using a gait belt. 3. A client with exacerbation of COPD reporting dyspnea. This client is not the nurse's first priority. d. Counting radial pulse, 100. Correct: The client has the right to be involved in the decision making of their care. a. Notify the board of nursing (BON) that the float nurse is an alcoholic. A nurse is preparing to obtain a blood specimen from a client by venipuncture. _________________ (magnanimous), a. generous An increased temperature will have a direct effect on the brain's metabolism and function. 5. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. However, it remains true pain for this client and the client would need intervention to help manage this pain. b. This could cause a medical emergency. Which of the following findings associated with urinary retention should the nurse expect? M2.4 Making Client Care Assignments - GECC.pdf - Course Hero Select all that apply. Involve the client in their plan of care. b. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). 6. the nurse responds: "It must be very frustrating to encounter this kind of attitude." b. b. 1., 2., 3., & 4. 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. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. a. c. Foot c. Complete an incident report Each ROM movement should be repeated 5 times during the session. b. I will keep the fluorescent ceiling light on in my room at night A client on a surgical unit frequently quarrels with the staff. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Female client stating she has been raped. 3. The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). Nursing Brain Sheet 4 Patients - luoe.expertoendermatologia.es Relief of urinary retention Nothing life threatening, but an assessment needs to be made regarding the ulcer. a. Call the client's provider The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. Relax her abdominal muscles when she lifts an object a. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). This is outside the scope of practice for the LPN/LVN. 4. Temporary urinary retention Which prescription should the nurse question and have corrected? Incorrect: This response overlooks a potentially severe problem. Nursing questions and answers. 4. Review the action of insulin therapy A nurse is caring for a client who is scheduled for an elective surgical procedure. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. The nurse is planning care for a client admitted with Alzheimer's Disease. Which of the following actions is an example of a violation of confidentiality? Incorrect: This again is assessment which is the role of the RN only. 3. When asking the client about his receptiveness to the transfer 2. 2. Gather and apply dressings to open wounds. American Sickle Cell Anemia Association The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). 1. The nurse would then start the 24 hour urine once the 1st void has been discarded. c. Gender A nurse is caring for a client who has emphysema and has difficulty with mobility. The charge nurse is developing patient care assignments for the evening shift and needs to assign clients to a licensed practical nurse/licensed vocational nurse (LPN/LVN) and a certified nursing assistant (CNA). c. The client was restless and trying to get out of the bed all evening Have a pen and paper handy Encourage the client to use self-exploration d. I have a set of my brothers' crutches in the basement I can also use, a. A nurse asks a client how he is feeling. When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. A client requesting assistance packing his belongings for discharge later today., 2. 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. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. Respite care allows the primary caregiver time away from day-to-day care responsibilities 4. c. Assist the client to the floor and begin mouth-to-mouth A nurse is orienting a new assistive personal (AP) to the unit. d. Do you think crying will help? c. I'll wear low heeled shoes from now on -Review a low-sodium diet for a client who has HTN Incorrect: What seems to be going on with this client? Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. The nurse suggest that the family might need to respite care services. Which of the following methods should the nurse plan to use? b. Irrigate the wound with an antiseptic prior to obtaining the specimen a. This service began with the client's admission to the hospital This schedule may leave some clients too exhausted to visit with family. Incorrect: The client does need to have food; however, there is another action that should be performed first. So, the UAP can assist a client to brush and floss teeth. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. 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. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Which of the following statements should the nurse identify as an indication the client needs further teaching? 5. Nothing will get passed the complete blockage. a. Explain to the RN that all the nurses have the same number of clients. Select all that apply b. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. If a sentence is already correct, write CCC. Assist the float nurse with the clients case. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. (Select all that apply.) 4. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. 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 using the communication principle of presence when establishing a collaborative relationship with a client. Convenience for the nursing staff or the client's family The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage 4. a. b. TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . The nurse should use close-ended questions when assessing which of the following factors? Who should the nurse see first? Inform the client of the need to avoid irritants such as carbonated beverages. b. The key word in the stem is first. 10. Briefly assess every client. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Ambulating a client who is 2 days post vaginal hysterectomy Administer tap water enemas until clear at 6 AM. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Client to receive dietary education. 4. Tenderness over the symphysis pubis Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. b. The area surrounding the insertion site feels warm to the touch, 61. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. The expected standard of care was strict bed rest), 96. 4. NURSING ASSIGNMENT- delegation in the workplace | Studymonk 1. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Normally, red blood cells are flexible and round, moving easily through blood vessels. 1. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Incorrect: This is not completely practical for everyone. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. Which of the following actions should the nurse take? I'm drinking plenty of fluids." When determining if the client is eating a well-balanced diet Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Incorrect: This group of clients needs specialized care. It is within the LPNs scope of practice to administer antibiotics. Four clients arrive for their appointment at a diabetic clinic. A nurse instructs a female client about collecting a midstream urine sample. b. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. c. The nurse may serve as a witness to informed consent for organ donation A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. b. Massage any bony prominences to promote circulation Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. Decide which choice fits best in the blank. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. A practical guide to making patient assignments in acute care A nurse is preparing a sterile field. Perform range of motion (ROM) exercises at least 2-3 times daily UAPs can assist with elimination and are taught how to measure output. Place in priority order. c. Leave a nightlight on in the client's room The nurse has just completed a 12 hour shift. & 6. b. a. Monitor for behavioral changes. the nurse responds, "don't worry, no one will harm your family." b. Correct: Communication is important in delegation, as is follow-up. This can prevent harm to client's. Client with chronic emphysema experiencing mild shortness of breath. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. This is a diabetic clinic. Measure urine output when client voids. 3. 3. 4. Moistening the dentures prior to inserting them There are a total of 10 adult clients. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". A nurse is developing a plan of care for a client who does not speak the same language as the nurse. The last client would be the one needing dietary education. Tenderness over the symphysis pubis A nurse is planning care for a female client who has an indwelling urinary catheter. Stand directly in front of the client In what order should the emergency department triage nurse send these clients to a room for treatment? Once the client is stable, the UAP could perform this task. d. Let's wait until tonight to see if he continues his behavior, 63. Reach around the pack and open the top flap away from the body, 53. Make referrals to community services. Select all that apply which client would be most appropriate to assign a licensed practical nurse (lpn)? Which of the following types of communication breakdown does this response represent? b. A client receives a wrong medication. A nurse is caring for a client who is postoperative. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. The spouse can rescind the Advance Directive if the client becomes unresponsive.

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