a charge nurse is making client care assignments

c. Washes and rinses her hands for 10 seconds A nurse is orienting a new assistive personal (AP) to the unit. 3. c. Provide the client with a diet high in protein Which of the following instructions should the nurse include? Remember airway, breathing and circulation (ABCs). One important aspect is encouraging the flow of ideas between management and staff members. a. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 1. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which preoperative prescription should the nurse question? 4. Which of the following actions is an example of a violation of confidentiality? 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). Which of the following actions should the nurse take? 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. The best practice committee works to improve clinical practice based on current research. Correct: The client may be experiencing a myocardial infarction and requires further assessment. 1., 2., 3., & 4. Incorrect: The nurse is responsible for evaluating a client. 2. The client says, "go away, no one can help me." Which of the following actions indicates that the AP understands the principles of infection control? 2. a. A charge nurse is making client care assignments. Teach the UAP to change surgical dressings. (Select all that apply.) Decide which choice fits best in the blank. 3. c. The emphasis is on the client's complete recovery from the illness or injury The cause of the fall may be cardiac, but the question does not indicate this. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. 2. Determine which personnel could be sent to the command center. Select all that apply You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. d. Droplet, d. Bend at the knees when picking up an object, 98. d. Do you think crying will help? Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? The nurse should perform which of the following activities in this space? The client attempted to climb over the side rails and fell Both of these clients are terminal. . Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. A nurse is teaching a client who has a history of falls about home safety. The client must understand the need for restraints The last client would be the one needing dietary education. 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. This is not a situation that requires the LPN to notify the primary healthcare provider. The client post PEG placement is stable. Which group of clients should she assign to the medical surgical nurse? a. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? a. A nurse is assessing a client who is experiencing prostatic hypertrophy. There is a possibility that a hypothermia blanket may be prescribed. The nurse received a client following surgery 8 hours ago. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. A nurse is caring for a client who has a hip fracture that requires surgical repair. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. 1. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. However, there are some basic points which are standard among all facilities. Channel a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter d. 216, 22. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? So, the UAP can assist a client to brush and floss teeth. Which of the following instructions should the nurse include? c. Washes and rinses her hands for 10 seconds, 11. Which of the following actions should the nurse take to assist the client with feeding? b. b. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. b. I will bear the weight of my body on my hands A nurse is teaching a client about the physical effects of chemotherapy. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). 3. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. Semi-formed stools are great news! 3. b. Following the teaching, the nurse asks the client to describe one physical effect. A home health nurse is conducting a home safety assessment for an older adult client. b. Provides safe, effective delivery of patient care in . 4. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 5. c. Foot Select all that apply Incorrect: This client is exhibiting early signs of increased intracranial pressure. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department The supervisor can only send one LPN/LVN to the floor. d. Bend at the knees when picking up an object, 99. 1. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. Which of the following statements should the preceptor make? Warm the feeding solution to the body temperature 2. b. Grape juice Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 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. Administer tap water enemas until clear at 6 AM. c. Rephrase statements the client does not hear A nurse is preparing medication for a client when another client has an emergency. Incorrect: This group of clients needs specialized care. b. Select all that apply. 2. b. I'm so sorry to hear about this Hanging a new bag of total parenteral nutrition (TPN). 2. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Left upper forearm 2. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Well, do you see the q.d.? 2. c. The client was restless and trying to get out of the bed all evening Dexlansoprazole 30 mg PO daily. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 3. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Normally, red blood cells are flexible and round, moving easily through blood vessels. Placing the traction weights on the bed to transfer the client to x-ray. 2. Observe the client before taking further actions A nurse is caring for a client who is postoperative following an appendectomy. Irrigate a client's ear canal. The nurse is reviewing some clients' prescriptions. An LPN/VN has been floated to the emergency room following a chemical plant explosion. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. "The client is weak on the right side, so please assist the client with dressing . A nurse is completing discharge teaching with a client. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. 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. Incorrect: This prescription is written correctly. 1. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Changing a colostomy bag. Incorrect: What seems to be going on with this client? b. 4. Refuse the overtime assignment, being prepared for disciplinary action. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Notify the charge nurse of the observations. This action is a defensive intervention, and does not address the quarrelsome behavior. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. A nurse is caring for a client who is immobile. 2. c. I will cover the catheter so he cannot see it Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. A nurse is caring for an older client who is at risk for skin breakdown. 2. 212 Which client should the nurse assess first? 1. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. b. 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. Correct: An LPN should be assigned clients with predictable outcomes. The client is considered unstable until assessed by the nurse. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). e. Dysuria, 49. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day 1. When a family member asks how respite care can help, which of the following responses should the nurse provide? 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The nurse voices his concern to the charge nurse. This protein is released by cells in the stomach. b. I can detect the presence of carbon monoxide by a metallic odor Which task should the nurse take responsibility for completing? However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. The nurse should assess the client for which of the following expected outcomes after catheter removal? b. Briefly assess every client. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. 4. 4. Cystogram reporting burning on urination. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. 1. 3. b. Convenience for the nursing staff or the client's family It also helps the client deal with issues that are important to him), 19. Providing a passive response Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) 4. 2. Obtain a bedside commode for the client's use 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. This task cannot be delegated to the LPN/LVN. Drag and Drop the items from one box to the other. 3. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. Did you think dehydration and fluid volume deficit? Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. c. Hallucinations at the onset of sleep What client should the nurse assess first? Which prescription should the nurse question and have corrected? Correct: Disconnecting NG tube suction is an appropriate task for the UAP. They are able to manage tasks related to basic care. c. I'll wear low heeled shoes from now on Assist a client to ambulate using a gait belt. 3. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Encourage the client to be more cooperative. Obtain a urine specimen from a client with an indwelling Foley catheter. 4. 2. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. The nurse cannot allow the UAP to perform advanced tasks. 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. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Nurses dependent on drugs or alcohol can harm clients. When asking the client about his receptiveness to the transfer Wears a gown when entering the room of a client who requires contact precautions Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? b. b. Client eating a simple-carb snack due to weakness. 3. 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. Correct: Hot water may damage dentures so intervention is needed. Which of the following findings should the nurse identify as a safety risk? Correct: This group of clients is primarily med surgical. Based on this information,what should the nurse do? Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. Select all that apply. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. c. Offer the client personal thoughts and beliefs a. The provider must renew a restraint prescription every 8 hr. Which of the following responses should the nurse make? Which of the following tasks should the nurse delegate to assistive personnel (AP)? Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. A float nurse arrives on the unit to assist in the care of clients for the shift. b. The nurse should call for immediate help so that a safe care environment is maintained for all clients. 1. Which of the following statements should the nurse make? Which action by an unlicensed nursing assistant would require the nurse to intervene? 2. Which actions should be instituted by each unit's charge nurse? c. Use intermittent eye contact d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. Teaching about a medication Could you try contacting a support group c. I will complete the smoking cessation program I started It can result in muscle spasm and tissue damage. Which of the following should the nurse identify as an interpersonal variable? Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. b. Verbalize understanding of how the client feels c. Palpating for pedal edema A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. Notify the nursing supervisor of the situation. 3. a. 3. - Assisting a client to ambulate using a gait belt. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. When the licensed person cannot determine this, the task should not be delegated. It would not be appropriate to overload this new employee with extra work. Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. a. 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. A charge nurse is making assignments for an oncoming shift. Assist client to brush and floss teeth. Feed a client that had a stroke 3 months ago. a. Clarification Explain administration is demanding a decreased overtime. c. I'll need to shave the hair off the skin where I place the electrodes Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Assist the float nurse with the clients case. b. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Complete blockage of the large intestine. 4. This is a task that can be delegated to the LPN/LVN. A nurse is caring for a client who expresses anxiety about his impending surgery. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Incorrect: Informing is the same thing as teaching. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. The nurse should not be assigned to provide care if impairment is suspected. The below statement corresponds to a numbered sentence in the passage. c. Hand-off technique Something new could have occurred with the clients, making the assignments too heavy. 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. a. Remind the client that a signed informed consent form is a legally binding document 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. Which of the following actions should the nurse take? "Please explain what you mean by the word 'nervous'.". b. I will come back later and we can talk A nurse is planning to discharge a client who has quadriplegia to his home. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 1. Which of the following info should the nurse include? Document current functional status assessment b. Select all that apply. c. Nonfat milk Correct: An LPN/LVN's scope of practice includes tasks such as wound care. 4. 4. The nurse would then start the 24 hour urine once the 1st void has been discarded. To which of the following rooms should the nurse assign the client? Perform range of motion (ROM) exercises at least 2-3 times daily Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. 3. Which of the following findings should the nurse expect? A nurse is discussing the norming stage of the group development process with a student nurse. The nurse is using which of the following therapeutic communication techniques? 2. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Fruity breath. 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. d. Ambulating the client in the hallway, c. Explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on affective learning), 80.

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