Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. 4. This task cannot be delegated to the LPN/LVN. Incorrect: This prescription is written correctly. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. Incorrect: This again is assessment which is the role of the RN only. 1. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? 1. Write N next to the nonessential clauses and E next to the essential clauses. 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 indicate they wish to be a DNR client if their heart stops beating or they stop breathing. Patient safety must remain the priority. Triage and assign color-coded tags to each client. c. Tie linen bags securely at the top The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The provider must renew a restraint prescription every 8 hr. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Furosemide 40 mg PO q.d. The nurse considers various ideas submitted by team members. The client with cystitis is stable and has a predictable outcome. 2. d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. Well, do you see the q.d.? A nurse is providing care to a client who is on strict bed rest following surgery. It also helps the client deal with issues that are important to him), 19. The nurse voices his concern to the charge nurse. A list of current medications is sent to the facility. A nurse is teaching a client about carbon monoxide poisoning. 4. 2. Client diagnosed with inoperative brain tumor who is confused. & 3. Which referral would most likely be appropriate for the nurse to make? The nurse voices his concern to the charge nurse. c. Helping the client into the shower b. Numbness Which of the following should the nurse include as a criterion for applying restraints? This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 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. 2. Which of the following instructions should the nurse include? a. Provide an adaptive feeding device for the client, 50. What interventions can the nurse delegate to the LPN/VN? 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 Correct: Communication is important in delegation, as is follow-up. b. 5. The nurse has another priority. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. The LPN/LVN can reinforce teaching. A nurse is administering a cold therapy application to a client. b. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Where on the body is each type of skin found? So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. 4. Which client should be assigned to the most experienced nurse? A charge nurse is making client care assignments. Call the client's provider There is a possibility that a hypothermia blanket may be prescribed. Gown Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. Place the client in a lateral position Incorrect: There are situations in which the LPN must notify the primary healthcare provider. The nurse does not know the skills of the new UAP. c. Offer the client personal thoughts and beliefs Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? Perform the Heimlich maneuver b. Encourage client to express grief related to loss of independence. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Gather supplies to prepare room for isolation. c. Malpractice c. Initiate a liquid diet for the client 9. -Review a low-sodium diet for a client who has HTN Send a day's worth of medications with the client to the receiving facility. A nurse has just finished a wound irrigation for a client who requires contact precautions. They have found my address and are coming for my family!" ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. A client requesting assistance packing his belongings for discharge later today.. a. Currently, your census is 11, with one empty bed. 1., 2., 4., & 5. 4. 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. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. d. Social conversation, a. b. I will come back later and we can talk Use double bagging to remove soiled linen from the client's room 3. D. 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. 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 Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Which of the following should the nurse identify as an interpersonal variable? 2. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. Select all that apply c. Notifying the provider of physical exam findings A nurse is caring for a client who is postoperative following an appendectomy. 3. a. Elicit info from the client 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. a. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. 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. Nurses dependent on drugs or alcohol can harm clients. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Which of the following responses should the nurse make? This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. 1. To remove gastric acid that might cause dyspepsia The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. Which client can be assigned to the LPN? Which of the following communication techniques should the nurse use during this phase? Elderly client who fell and fractured the left femoral neck. a. d. Counting radial pulse, 100. This could cause a medical emergency. (Select all that apply.) The charge nurse is planning the staff assignments for the clients on a neurological unit. 1. a. Hypotension The first vital sign check was performed by the nurse. Correct: An LPN should be assigned clients with predictable outcomes. 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. 4. 1., 2., 3., & 4. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Refuse the delegated intervention. Temporary urinary retention (common for clients to develop after removal), 90. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. The abdominal pain is worsening. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Place in priority order. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. A charge nurse is making assignments for an oncoming shift. Which client should the nurse assess first? 1. 1. c. I'll wear low heeled shoes from now on A nurse instructs a female client about collecting a midstream urine sample. 208 2. 2. 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. 2. d. Left forearm, b. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. 3. Nothing life threatening, but an assessment needs to be made regarding the ulcer. It happened so long ago - just get over it!" 2. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. b. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. b. UAPs can assist with elimination and are taught how to measure output. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. 2. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. 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. b. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. Make referrals to community services. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day Administer sodium polystyrene sulfonate enema. The RN with 8 years' experience in the Intensive Care Unit. 4. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Did you think dehydration and fluid volume deficit? 3. Ask the primary healthcare provider to suggest the best oral care procedure. 2. Call the family of a client suffering from dementia to discuss long term care placement. The client is reporting anxiety, discomfort, and a feeling of bloating. b. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Correct: Traction should never be relieved without a primary healthcare provider's prescription. 5. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). 2. A two-hour limit on visits discourages quality time. Which of the following actions should the nurse take? d. Let's wait until tonight to see if he continues his behavior, 63. Following the teaching, the nurse asks the client to describe one physical effect. c. There is fluid leaking around the insertion site These individuals are selected by the charge nurse, and do not have to be nurses. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 4. a. 5. 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. Select all that apply. The reason for the UAP not feeding the client needs to be determined. The nurse should do this when repositioning is needed. b. Incorrect: The charge nurse does not have to assess every client. An LPN/VN has been floated to the emergency room following a chemical plant explosion. a. Placing the traction weights on the bed to transfer the client to x-ray. It can result in muscle spasm and tissue damage. }? benefactor of the world. 3. c. The client was restless and trying to get out of the bed all evening Assist a client to ambulate using a gait belt. d. Perception A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Who should the nurse see first? (Select all that apply.). Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? 1. A nurse is caring for a client who has limited hand movement. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Which of the following statements should the nurse make? 6. b. Massage any bony prominences to promote circulation 4. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Temporary urinary retention Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. Incorrect: Moistening the dentures will ease insertion. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. 2. b. 1. Which of the following responses should the nurse make? The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. 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. Report of feeling pressure Reporting laboratory findings to a member of the client's family 3. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. The last client would be the one needing dietary education. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. A nurse is teaching a client who has a history of falls about home safety. Announce the new changes at the monthly staff meeting. Which of the following is the priority action by the nurse? d. Discussing intake and output A client has been admitted with folic acid deficiency anemia. 1. 4. c. Can you tell me why you chose me? 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. d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter Teaching about a medication Perform range of motion (ROM) exercises at least 2-3 times daily Which of the following tasks should the nurse delegate to assistive personnel (AP)? d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 3. Briefly assess every client. b. 1. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." 2. So what is wrong with option #1? Select all that apply 2. 2. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. 2. Discussing a client's surgical procedure with the nurse manager c. Confrontation d. Anger, b. The nurse should not be assigned to provide care if impairment is suspected. Teach caregivers memory enhancement aids. "The client is weak on the right side, so please assist the client with dressing . Select all that apply Elderly clients have special fluid and electrolyte issues after a fall. d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. d. Mask, 83. One nurse lifting as the client pushes with his feet A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. 4. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. This is outside the scope of practice for the LPN/LVN. 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 1. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. 3. 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. The nurse should use close-ended questions when assessing which of the following factors? d. Wait to discuss the behavior in the presence of others, a. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. 1. Only a plain enema or soap enema can be given by the UAP. Decreased or suppressed respiration are priority. 7. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. 2. Which of the following instructions should the nurse include? A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. The nurse is reviewing some clients' prescriptions. Include any relevant statements the client made about the ulcer c. Rephrase statements the client does not hear Discuss the competency of the surgeon Select all that apply c. Shivering They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. 2. In order to reorganize staffing, the nurse manager should initiate which action first? To confirm the placement of the NG tube which of the following actions should the nurse perform? d. Bend at the knees when picking up an object, 99. a. Asking for an explanation d. Respite care is a continuation of psychological support after a family member dies. The charge nurse must triage and assign clients to appropriate staff. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Decreased RBC production c. The nurse may serve as a witness to informed consent for organ donation a. Shakes the soiled linen to remove any toilet paper remnants Transfer essential medical record to the receiving facility. d. Voided 30 mL frequently Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Encourage clients and families to develop mutually appropriate visitation times. Nothing life threatening. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. 3. c. Visual observation for nonverbal signs of pain b. I will try to anticipate and avoid stressful situations when possible The nurse is using which level of communication at this time? Monitor client for pain while assisting with ambulation. Feedback b. Verbalize understanding of how the client feels Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. 2. e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Incorrect: The nurse is responsible for evaluating a client. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. b. Charge nurses have integral roles in healthcare organizations. 2. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Providing hygiene care to a client who is HIV positive This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. A nurse is planning to discharge a client who has quadriplegia to his home. Which of the following findings associated with urinary retention should the nurse expect? 2. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. Which of the following statements should the nurse make? 3. Dentures should be stored in a denture cup. They are able to manage tasks related to basic care. a. 3. c. Foot d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. 1. 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. 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. 2. Female client stating she has been raped. 2. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. For which of the following tasks should the nurse wear protective eye equipment. c. Hold an object away from her body as she lifts it d. Proceed with the preparation of the patient's surgical procedure, 15. This situation is considered an external disaster which means the hospital will be expecting multiple victims. A lack of rapid eye movement (REM) sleep 1. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Assign more daily tasks to the UAP. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. a. Client eating a simple-carb snack due to weakness. The client receives home health care and spends most of his day in a reclining chair. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. a. Try different methods of oral care on unresponsive clients to see what works best. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). Client who is a diabetic experiencing diabetic neuropathy. The spouse can rescind the Advance Directive if the client becomes unresponsive. Changing the subject 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. This service began with the client's admission to the hospital Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. An adult (18 years or older) can create an advanced directive. Initiate oxygen and IV lines as needed. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. (Select all that apply.) b. eminent Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Which of the following tasks should the charge nurse reassign to a licensed nurse? Assist ait to ambulate using a gait belt. Correct. b. Wash the area of the puncture thoroughly with soap and water joe dispenza coherence healing meditation,

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