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. A nurse is caring for a client who has a hip fracture that requires surgical repair. The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. 1. Risperidone .5 mg PO daily Monitor for behavioral changes. Providing a passive response a. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. Normally, red blood cells are flexible and round, moving easily through blood vessels. 5. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. The nurse should not be assigned to provide care if impairment is suspected. 1. Donning gloves and using a gauze pad to grasp and remove dentures Pain Nothing will get passed the complete blockage. b. 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. Client who is a diabetic experiencing diabetic neuropathy. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. b. d. Complete an incident report, 70. c. Open the right flap with the left hand b. a. This action is a defensive intervention, and does not address the quarrelsome behavior. b. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. a. Thus, the tasks involve successful management of the charge nurse's responsibilities. c. Behaving defensively EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 4. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). c. Do not eat or drink anything the morning of the test Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. a. Measuring vital signs In what order should the nurse see the clients? a. 2. Refuse the delegated intervention. b. 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. Fundamentals Practice Flashcards | Quizlet 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). a. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. Select all that apply c. Inflate the balloon when the urine flow stops Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Reach around the pack and open the top flap away from the body A nurse is performing care activities for a client in the zone of touch that requires his consent. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. The nurse should assess the client for which of the following expected outcomes after catheter removal? 4. & 3. 2. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 5. d. Talk with the client's partner, b. d. I shouldn't advice you about what is ultimately a personal decision, b. one of the licensed practical nurses Get the answers you need, now! This could indicate a worsening of this client's condition. a. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? d. Go to employee health services, b. Relax her abdominal muscles when she lifts an object Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. 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. -Review a low-sodium diet for a client who has HTN Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Incorrect: The RN is responsible for assessment and evaluation. Which of the following statements should the nurse make? 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. The nurse is using which of the following therapeutic communication techniques? The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. 4. 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. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. 4. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A nurse is caring for a client who is about to have a colonoscopy. 1. To which of the following rooms should the nurse assign the client? An adult (18 years or older) can create an advanced directive. Speak to the UAP to determine what happened with the feeding. 4. 4. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. c. Inform the surgical team to cancel the client's surgery a. Auscultate breath should at least ever 2 hr Incorrect: The concern here is the client being fed their meal. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. b. A client receiving heparin injections for deep vein thrombosis. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. A nurse is caring for a client who is scheduled for an elective surgical procedure. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. b. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Remind the client that a signed informed consent form is a legally binding document Correct. 3. 1. Which of the following statements should the nurse make? 3. c. Distended bladder A nurse is filling out an incident report after finding a client lying on the floor. b. The provider must renew a restraint prescription every 8 hr. 2. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. 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. 3. 2. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. A nurse is teaching a client about carbon monoxide poisoning. 2. Drag and Drop the items from one box to the other. 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. a. Broth 3. A nurse asks a client to share personal stories. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. a. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Client one day post kidney transplant. The charge nurse needs additional information to make a decision. The client then states, "I have changed my mind and do not want to have the procedure done." 3. d. Social conversation, a. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. There is a trailing zero after the prescribed dose. Correct: Communication is important in delegation, as is follow-up. 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). Select all that apply. b. b. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. a. Incorrect: The nurse retains the responsibility for the delegated task. Ask the primary healthcare provider to suggest the best oral care procedure. However, providing care for missing teeth would also be within the LPN scope of practice. Making client care assignments As the RN charge | Chegg.com Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? IV of D5 NS at 75 mL/hour with a 20 gauge catheter. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. a. b. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. What information should the nurse include? a. Reposition the client every 3 hr c. I will place an area rug at the entry of my bathroom a. Showing disapproval December 5, 2020. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Soaking the dentures in hot water "Please explain what you mean by the word 'nervous'.". Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. In which situation should the nurse consult the client's advanced directive? 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. c. Discard any residual gastric contents Call the client's provider 1. Following the teaching, the nurse asks the client to describe one physical effect. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. a. I will keep my walker at the end of my bed Therefore, this client would not be a priority over a client who may be experiencing a MI. 2. 2. 4. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? b. Numbness 1. b. What should the nurse do first? A nurse is caring for a client who has limited hand movement. a. I'll provide more stimulation in his environment Discussing a client's surgical procedure with the nurse manager Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. C-section planning discharge, postpartum infection, mastectomy. Encourage client to express grief related to loss of independence. Ask client if they are eating small, frequent meals. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. 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. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. The third client that should be sent back for treatment is the female client stating she has been raped. c. Check to see if the suction equipment is working a. c. Hallucinations at the onset of sleep 3. The expected standard of care was strict bed rest), 96. a. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. A nurse is teaching a client about the physical effects of chemotherapy. The last client would be the one needing dietary education. Alcoholic Anonymous d. Left forearm, b. b. Have a pen and paper handy Changing the subject Select all that apply This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. The nurse is focusing on which of the following elements of the communication process? Which of the following should the nurse include as a criterion for applying restraints? Feedback Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 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. c. There is fluid leaking around the insertion site Administering IV pain medication to a two day post op client. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 4. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. 1. a. Bathe a client who had an amputation 2 days ago 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. This client should report an improved respiratory, not shortness of breath. A nurse is developing a plan of care for a client who practices Islam. 1. Which of the following physiological responses to prolonged immobility should the nurse expect? A nurse instructs a female client about collecting a midstream urine sample. e. Throw rugs, 40. Determining the client's length of stay c. Measurement of residual urine after urination The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. The client states, "I'm feeling a bit nervous today." It is within the LPNs scope of practice to administer antibiotics. 3. A client who is disoriented and awaiting transfer to a long-term care facility. c. 214 a. Printable Nursing Brain SheetPrintable Nursing - soyu.caritaselda.es Based on this information,what should the nurse do? b. Write N next to the nonessential clauses and E next to the essential clauses. There are a total of 10 adult clients. a. Select all that apply. 3. A charge nurse is making client care assignments. Patient safety must remain the priority. Discuss the issue with the leader of the "best practices" committee. c. Helping the client into the shower 1. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. 3. Currently, your census is 11, with one empty bed. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Furosemide 40 mg PO q.d. Feed a client that had a stroke 3 months ago. A list of current medications is sent to the facility. A family member requests that the nurse apply restraints. b. I should call my doctor if I find it harder to concentrate a. Which of the following approaches should the nurse use when using confrontation? Because the charge nurse observes and weighs . Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Which tasks should the charge nurse delegate to the nursing assistant? Correct: The client may be experiencing a myocardial infarction and requires further assessment. A high concentration of carbon monoxide can cause death The stem does not indicate any loss of neurological function resulting from the seizure activity. Which of the following actions should the nurse take prior to administering the tube feeding? A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. b. Assess the client M4 Client Care Assignment.pdf - Making Client Care A nurse is planning to discharge a client who has quadriplegia to his home. d. Perception c. Explore the client's feelings about dietary modifications This protein is released by cells in the stomach. To remove gastric acid that might cause dyspepsia b. d. Services are centered in long-term care facilities, a. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? The charge nurse might not have realized all the responsibilities of taking this team of clients. Perform catheterization when you recognize the urge to void All these clients have a GI problem. a. I'll sit with my knees lower than my hips Tenderness over the symphysis pubis Incorrect: The nurse is responsible for evaluating a client. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Explain to the RN that all the nurses have the same number of clients. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. This is an elderly client who is a new admit. Incorrect: The nurse cannot assign teaching to the UAP. A client receives a wrong medication. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Start MgSO4 at 3g/hr IV 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. The reason for the UAP not feeding the client needs to be determined. a. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). Suggest splitting the shift with another nurse. 4., & 5. Incorrect: This is not completely practical for everyone. The client was lying on the floor next to his bed d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. c. I will make sure my visitors smoke outside Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. Rewrite each incorrect sentence to correct the error. Show client who has conjunctivitis how to clean the eyes. 3. c. Explain the risks and benefits of the procedure A goal for this client is to use proper body mechanics at all times. This client is stable and predictable. Teaching insulin self administration to a diabetic client. Ambulating a client who is 2 days post vaginal hysterectomy Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? This individual should be provided appropriate comments of appreciation for this accomplishment. This client can wait until the others are treated. Pernicious Anemia Society a. Each ROM movement should be repeated 5 times during the session. Based on these findings, to which of the following providers should the nurse request a referral for the client? A two-hour limit on visits discourages quality time. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. e. Dysuria, 49. b. This referral would be appropriate. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. An LPN/VN has been floated to the emergency room following a chemical plant explosion. Notify clients that the disaster plan has been put into effect. b. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Incorrect: The client does need to have food; however, there is another action that should be performed first. 1. e. Talking with the client's partner, 79. Which of the following actions should the nurse take to assist the client with feeding? A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. A nurse is providing care to a client who is on strict bed rest following surgery. The nurse received a client following surgery 8 hours ago. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. 2. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., 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). Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Obtain a client's consent 3. Ask the RN why the assignment is too heavy. Place the client in a lateral position Which of the following actions should the nurse take? Nothing life threatening, but an assessment needs to be made regarding the ulcer. c. Review the client's progress toward personal objectives Administer sodium polystyrene sulfonate enema. 3. Assist client to brush and floss teeth. 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. The client states, "I am so nervous about what the doctor might find during the test." The cleint's family asks the nurse for info about this type of care. It's unfortunate that I have to be in the hospital for this treatment A nurse is having difficulty caring for a client due to variables affecting the communication process. Something new could have occurred with the clients, making the assignments too heavy. c. Document in the client's medical record that she completed an incident report The situation should be explored before bringing the supervisor in on the situation. Remove all metal necklaces Vital sign measurement What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? 2. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. Right forearm Incorrect: Teaching is outside the scope of practice for the LPN/LVN. They have found my address and are coming for my family!" Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. a. Invite staff to contribute ideas on scheduling changes. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. 4. b. c. Take the client to the bathroom every 2 hr Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 2) Assist a client to ambulate using a gait belt. a. Auscultating heart sounds This documentation should go to your manager. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously.
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