American Sickle Cell Anemia Association Incorrect: Atrial fibrillation places the client at risk for blood clots. 3. c. Include intact skin at the wound edges in the culture c. Discard the tablet and obtain another dose of medication a. Include any relevant statements the client made about the ulcer, 64. What action should the nurse take after mistakenly administering the wrong medication? Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Injuries from a motor-vehicle accident can be life threatening. The spouse can rescind the Advance Directive if the client becomes unresponsive. One nurse lifting as the client pushes with his feet 2. 3. Hanging a new bag of total parenteral nutrition (TPN). c. Environment The client would develop severe cramping. 3. a. Answer the following question to test your understanding of the preceding section: a. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Feedback Which of the following statements should the nurse identify as an indication that the client needs further teaching? Incorrect: Informing is the same thing as teaching. (Select all that apply.) In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. 3. Review a low-sodium diet for a client with hypertension. b. I will call the doctor and get the prescription It contains a blank and is followed by four answer choices. Semi-formed stools are great news! a. C-section planning discharge, postpartum infection, mastectomy. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. 1. Teach caregivers memory enhancement aids. Turn on local news for up-to-date information on the train derailment. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. 4. Incorrect: This group of clients needs specific teaching. b. Which of the following indications should the nurse include? d. Identifying the client by name when making a referral for home health services, 30. a. 1. b. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. Select all that apply d. I shouldn't advice you about what is ultimately a personal decision, b. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). Alert all off-duty personnel to stand by in case of call- in. Nothing by mouth (NPO). For which of the following actions should the nurse intervene? Which of the following actions should the nurse take first? a. 76. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Nothing life threatening. c. Lock the medication in a room and finish preparing it after returning from the emergency (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. Accept the client's behavior as confrontational. b. A client receiving a blood transfusion that requires monitoring. A nurse is preparing to obtain a blood specimen from a client by venipuncture. Initiate oxygen and IV lines as needed. 4. Everything will be okay Which of the following statements by the student indicates understanding of the discussion? 3. a. Only the state Board of Nursing can legally determine the LPN's scope of practice. Which of the following responses should the nurse make? Which of the following instructions should the nurse include? PDF 8 steps for making effective nurse-patient assignments 1. Schedule visiting times in two-hour increments so clients are not overwhelmed. c. The client was restless and trying to get out of the bed all evening a. which of the following actions should the nurse perform? Solved A charge nurse is making client care assignments. | Chegg.com Correct: Disconnecting NG tube suction is an appropriate task for the UAP. This should not be delegated to the LPN/LVN. The nurse voices his concern to the charge nurse. Which of the following actions should the nurse take prior to administering the tube feeding? 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. 4. This individual should be provided appropriate comments of appreciation for this accomplishment. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. Provides day to day direction and supervision to assigned direct patient care staff. Who should the nurse see first? Gather and apply dressings to open wounds. Which of the following info should the nurse include? c. I'll wear low heeled shoes from now on There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 3. This is a diabetic clinic. 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. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. 5. We do not know the extent of her injuries based on what the option tells us. Correct: Communication is important in delegation, as is follow-up. Which action by an unlicensed nursing assistant would require the nurse to intervene? Notify the nursing supervisor of the situation. 4. Which of the following items should the nurse offer the client? Which task should the nurse take responsibility for completing? The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). There may be a good reason that the tray was not served. }? benefactor of the world. Currently, your census is 11, with one empty bed. A nurse is caring for a client who is postoperative following an appendectomy. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. a. Fundamentals Practice Flashcards | Quizlet Irrigate a client's ear canal. The body needs vitamin B12 to make red blood cells. (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 Focus on the client's present circumstances instead of his personal stories Inform the client of the need to avoid irritants such as carbonated beverages. A nurse has just finished a wound irrigation for a client who requires contact precautions. 2. Elderly client admitted 30 minutes ago with reports of constipation for four days. Correct. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. 2. They have found my address and are coming for my family!" 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 nurse in a clinic is teaching a group of clients about preventing low back pain and injury. A charge nurse is making client care assignments. 4. Speak to the UAP first and then decide if a between meal supplement is needed. b. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? butter, which contain 16 g of protein, 7 g of carbohydrates, 3. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. 4. 4. A nurse is caring for a client who frequently attempts to remove his IV catheter. 3. 3. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. What was the hint? c. Complete an incident report Client who has multiple injuries from a motor vehicle accident. Measuring vital signs To confirm the placement of the NG tube Female client stating she has been raped. 2. It's just not the right time for me to do this Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. Briefly assess every client. Channel Which of the following instructions should the nurse include? A practical guide to making patient assignments in acute care 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. 1. 2. a. A client with a fractured right humerus who reports the cast is too tight. In what order should the nurse assess assigned clients following shift report? A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. The RN with 5 years' experience in the Labor and Delivery unit. c. The restraints should promote the client's safety and prevent injuries Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? What is the best response by the charge nurse? c. Can you tell me why you chose me? 5. Describe the types of machining operations that can be performed on a lathe. 1. Discuss the issue with the leader of the "best practices" committee. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Could you try contacting a support group Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Correct: The medical nurse can be assigned to this client. The area surrounding the insertion site feels warm to the touch, 61. 4. Include any relevant statements the client made about the ulcer A charge nurse is making assignments for an oncoming shift. The nurse caring for the client at the time of death requests organ donation d. Place the tablet directly into a medication cup, 36. c. There is fluid leaking around the insertion site 1. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. Photo comes from the Greek word for light. a charge nurse is making client care assignments for the day. An LPN/VN has been floated to the emergency room following a chemical plant explosion. The LPN can monitor the wound and provide care to the PEG insertion site. Drag and Drop the items from one box to the other. 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. 2. The nurse is focusing on which of the following elements of the communication process? 1. 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: First, the local news does not necessarily have the most accurate information on the disaster. b. Wash the tablet off with alcohol and place it in a clean medicine cup Use adult diapers to prevent frequent clothing changes 2. 4. During exacerbation, the client will have many diarrhea stools. c. Decreased sodium excretion 6. A client with fibromyalgia reporting generalized pain of 7 out of 10. Administering 3 g/hr IV of morphine would be extremely dangerous. d. The nurse has already considered alternatives to restraints, a. Patient safety must remain the priority. The charge nurse needs additional information to make a decision. A nurse who is breastfeeding her 4 month old. If a sentence is already correct, write CCC. c. I will make sure my visitors smoke outside Assist a client to ambulate using a gait belt. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. Removing the abdominal dressing d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Provide a between meal supplement to the client. A nurse is caring for a client who has a wound infection. Disconnect client's nasogastric (NG) tube suction to allow ambulation. b. I will bear the weight of my body on my hands b. b. I will try to anticipate and avoid stressful situations when possible Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. d. Explain oral hygiene to a client receiving chemo Most of the following sentences contain errors in the use of modifiers and comparisons. The assignment process requires constant evaluation and reevaluation of information and priorities. a. Provide an adaptive feeding device for the client c. I will inspect my crutches everyday for signs of wear Based on this information,what should the nurse do? 1. 4. What is the primary factor for the charge nurse to consider when delegating care? 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. e. an open perineal wound, 92. Besides yourself, there are the following staff: Your unit has 12 beds. Providing a passive response & 6. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. 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. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. This service focuses on teaching the primary caregiver to meet the client's needs c. Visual observation for nonverbal signs of pain the nurse responds, "don't worry, no one will harm your family." c. Provide the client with a diet high in protein The client receives home health care and spends most of his day in a reclining chair. 3. a. Clarifying Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". e. The urge to move the legs when trying to sleep, 66. A cardiac step down unit has requested float staff because of multiple impending admissions. For which of the following tasks should the nurse wear protective eye equipment. 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. Vital sign measurement 5. Obtain a bedside commode for the client's use Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). A goal for this client is to use proper body mechanics at all times. Dentures should be stored in a denture cup. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. The charge nurse is making client assignments for a neuro-medical floor. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. The client should be assessed first to rule out respiratory difficulty and hemorrhage. 1., 2., 3., & 4. Cystogram reporting burning on urination. 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. 2. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. a. c. Notifying the provider of physical exam findings The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. b. Soaking the dentures in hot water Incorrect: The RN is responsible for collecting data. b. Reach around the pack and open the top flap away from the body c. I suggest you talk with a mental health counselor about your concerns c. Paraphrasing d. Reflection, c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation), 37. The healthcare team should recognize the client as the center of the team. Triage and assign color-coded tags to each client. Allow the UAP to work without supervision. b. Numbness So what is wrong with option #1? 1. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. c. Holds the soiled linen against her body while carrying it to the linen bag CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells.
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