LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. 1. a. 3. Making client care assignments As the RN charge | Chegg.com The nursing supervisor may be able to assist with client care until another nurse can come in to work. This client can wait until the others are treated. c. Face shield d. Discussing intake and output Assessing this client and titrating the diltiazem requires the skills of an RN. What is the most appropriate action by the charge nurse? 2. Well, do you see the q.d.? b. c. They tend to use more verbal communication Which of the following pieces of PPE should the nurse remove first? Thus, the tasks involve successful management of the charge nurse's responsibilities. Incorrect: This again is assessment which is the role of the RN only. 10. d. Remove tea and coffee from meal trays, b. The assignment process requires constant evaluation and reevaluation of information and priorities. c. Measurement of residual urine after urination In what order should the nurse assess assigned clients following shift report? Evaluate client's safety risk factors. Which of the following actions is the priority for the nurse to include in the client's plan of care? What is the best first action for the nurse to take in order to achieve this goal? Which of the following actions should the nurse take regarding informed consent? Symbolic communication 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. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. The key word in the stem is first. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? 2. 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. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. 2. Select all that apply Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. Female client stating she has been raped. Warm the feeding solution to the body temperature Assist a client to ambulate using a gait belt. A skill for which the ap has received instruction the - Course Hero a. Bathe a client who had an amputation 2 days ago 3. 5. 3. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. b. Verbalize understanding of how the client feels 4. Which of the following interventions should the nurse include? 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. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 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. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. 4. 4. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Incorrect: The RN is responsible for assessment and evaluation of clients. Notify clients that the disaster plan has been put into effect. Although this will require assessment, this client is not the priority at this time. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. d. Lean back in the chair, b. A nurse is performing care activities for a client in the zone of touch that requires his consent. The client asks about his medications and their effects. The nurse is using which of the following therapeutic communication techniques? The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. a. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. d. What have you done in the past to cope with this issue? Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? 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? What is the primary factor for the charge nurse to consider when delegating care? A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Remember airway, breathing and circulation (ABCs). (Select all that apply.) 2. Explain oral hygiene to a client receiving chemotherapy 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. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Select all that apply 1. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? b. Nurses Report Sheet Template Nicu. 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. 3. 2. Which of the following activities should the nurse perform in this zone? Turning off continuous tube feeding to reposition a client, then turning the feeding back on. 1. a. 2. Receive report from the emergency department (ED) on a new client. 3. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. a. 2. 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 charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. This action is a defensive intervention, and does not address the quarrelsome behavior. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. Accept the client's behavior as confrontational. 1. Check environment for potential safety hazards. 4., & 5. a. d. Anger, b. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. d. Motor impairment, 84. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. 4. (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? 3. The RN with 10 years' experience pulled from the ER. Following a large hurricane, multiple clients arrive at the emergency room for treatment. The facility has insurance that will cover malpractice litigation 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. 1. 4. Triage and assign color-coded tags to each client. b. I'll do exercises that strengthen my abdominal muscles Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Perform the Heimlich maneuver a. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). The client must understand the need for restraints 1., 2., 4., & 5. Select all that apply Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. c. Tie linen bags securely at the top Encourage clients and families to develop mutually appropriate visitation times. Which of the following actions should the nurse take prior to administering the tube feeding? If you give the magnesium citrate, which is a laxative, what will happen? A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. 2. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. c. Hand-off technique A nurse is preparing a sterile field. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse has just completed a 12 hour shift. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. The RN with 2 weeks' experience on the postpartum unit. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? 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. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. a. Elderly client admitted 30 minutes ago with reports of constipation for four days. These individuals are selected by the charge nurse, and do not have to be nurses. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 3. 1. a. I'll provide more stimulation in his environment A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Which of the following tasks should the charge nurse reassign to a licensed nurse? 3. Removing the abdominal dressing d. Transporting a cerebrospinal fluid specimen to the lab c. Discard any residual gastric contents b. I will call the doctor and get the prescription b. 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. 1., 2., 3., & 4. b. The nurse could definitely be part of the committee. e. Throw rugs, 40. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. c. Holds the soiled linen against her body while carrying it to the linen bag The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. M2.4 Making Client Care Assignments - GECC.pdf - Course Hero Incorrect: This group of clients needs specialized care. Feedback This client should report an improved respiratory, not shortness of breath. Talk to each nurse about concerns related to assigned clients. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Nothing by mouth (NPO). A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Understanding the charge nurse's role in staffing Ask the RN why the assignment is too heavy. c. The nurse may serve as a witness to informed consent for organ donation A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Narrative interaction 5. b. Now, in Option #2, we see a dangerous prescription. Elderly client who fell and fractured the left femoral neck. a. I will keep my walker at the end of my bed Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Notify the primary healthcare provider. A nurse is preparing medication for a client when another client has an emergency. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Feedback 2. Select all that apply. Change the subject when the client behaves defiantly 3. b. a. I will wear gloves when removing food from the freezer An adult (18 years or older) can create an advanced directive. c. Changing a dressing, 78. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Changing a colostomy bag. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. Cardiac catheterization with a decreased pedal pulse below insertion site. 1. It contains a blank and is followed by four answer choices. The situation should be explored before bringing the supervisor in on the situation. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. 4. Which of the following actions should the nurse take? 4. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. b. 3. Correct: Did you notice the hint? a. 76. Which of the following info should the nurse include? A high concentration of carbon monoxide can cause death The nurse voices his concern to the charge nurse. a. Drag and Drop the items from one box to the other. 3. This stage is when testing occurs to identify boundaries of interpersonal behaviors A nurse is prioritizing care for two clients at the start of the shift. Stand directly in front of the client 1. c. Notifying the provider of physical exam findings 3. What task would be best to assign to the LPN/LVN? Witness the client's signature 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. 5. 4. a. 2. Temporary urinary retention (common for clients to develop after removal), 90. Select all that apply c. Include intact skin at the wound edges in the culture Checking capillary refill beneath the client's fingernail c. Nonfat milk This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. Elevating the head of the bed 30- 40 for the client post thoracotomy 3. Sudden attacks of sleep Charge Nurse - RN | Fresenius Karriere Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. The nurse caring for the client at the time of death requests organ donation Which tasks should the charge nurse delegate to the nursing assistant? Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? 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. d. Go to employee health services, b. A nurse is caring for a client who has emphysema and has difficulty with mobility. During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate? On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. 1. A nurse is working with an assistive personnel (AP) to PDF 8 steps for making effective nurse-patient assignments However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Ask for any staff objections to rearranging work hours. 1., 2., 4., & 5. The nurse has been assigned four clients. 2. Select all that apply. D. 3. Which client should the nurse assess first? Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. 4. b. I'm so sorry to hear about this Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). 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. 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 1. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. Which of the following sites should the nurse plan to use to obtain the blood specimen? 1. Right forearm Problems in Delegation: A Busy Day on the Floor - Quizlet Which client would be appropriate for the RN to assign to the LPN? A nurse is caring for a client who has a wound infection. The nurse cannot allow the UAP to perform advanced tasks. Measure urine output when client voids. 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). Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Turn on local news for up-to-date information on the train derailment. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. a. This includes medication enemas. Assist client to brush and floss teeth. The client states, "I'm feeling a bit nervous today." 4. b. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. 5. 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 . Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. 2. A nurse is assessing a client who has narcolepsy. 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. b. Denial leadership management of care nurse on unit is providing care for group of clients. Correct: The medical nurse can be assigned to this client. 2. 3. b. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? Which of the following items should the nurse offer the client? Nursing questions and answers. This is normal for clients with hemorrhoids. b. a. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Monitor for GI upset 30 minutes after meals. 1. Plan all care to be completed in early morning to allow afternoon for visitation. Select all that apply. Teach the UAP to change surgical dressings. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. d. Remove and reinsert the NG tube, a. A nurse is planning to discharge a client who has quadriplegia to his home. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. 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. Could you try contacting a support group Correct. Airborne The client's self-report of pain severity This protein is released by cells in the stomach. a. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. 1. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? c. I suggest you talk with a mental health counselor about your concerns (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. Incorrect: Medications are not transferred with the client to a new facility. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? The RN with 8 years' experience in the Intensive Care Unit. 1. c. Offer the client personal thoughts and beliefs This could cause a medical emergency. Announce the new changes at the monthly staff meeting. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. The women's health charge nurse is making assignments for the next shift. Disconnect client's nasogastric (NG) tube suction to allow ambulation. d. Establishing the client's secondary medical diagnoses, b. b. Summarization Request a prescription for a medication to ease the client's anxiety 6. (SATA) -Bathing a client who had an amputation 2 days ago. This can prevent harm to client's. Show client who has conjunctivitis how to clean the eyes. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Decreased RBC production Education A goal for this client is to use proper body mechanics at all times. Take several shallow breaths during the procedure The nurse is caring for four clients. a. Elicit info from the client Include any relevant statements the client made about the ulcer, 64. Injuries from a motor-vehicle accident can be life threatening. Delegate 2 nurses to work with the client. The charge nurse might not have realized all the responsibilities of taking this team of clients. The primary healthcare provider may have suggestions but this is not the best first action. d. Assault, b. Which of the following actions should the nurse take? Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47. 4. 3. d. When asking if the client took his medications this morning, 82. 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. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Reach around the pack and open the top flap away from the body c. Palpating for pedal edema The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Assist a client to ambulate using a gait belt. The infusion rate has stopped but the tubing is not kinked What was the hint? 2. One important aspect is encouraging the flow of ideas between management and staff members. A nurse is caring for a client who states, "I have got to get out of this hospital! Place in priority order. 3. 1) Bathe a client who had an amputation 2 days ago. Assign a nursing assistant to help the client with self-care activities. A client diagnosed with rheumatoid arthritis needing discharge teaching. 212 The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 1., 2., 3., & 4. A nurse is teaching a client about the physical effects of chemotherapy. a. d. Reduced blood viscosity, a. Auscultating heart sounds A school-aged child with a fractured femur who is in balanced suspension traction. 3. a. b. a. Limit the client's fluid intake in the evening 1. 1. 1. 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. 2. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. 3. Client scheduled for breast reconstruction after mastectomy. Anyone over age 18 can have an Advanced directive. In order to reorganize staffing, the nurse manager should initiate which action first? A client post pacemaker insertion, awaiting discharge instructions. Explain administration is demanding a decreased overtime. 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. Remind the client to avoid tight fitting clothes. Something new could have occurred with the clients, making the assignments too heavy. Administer sodium polystyrene sulfonate enema. 1. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. 1. A nurse asks a client how he is feeling. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. b. The nurse voices his concern to the charge nurse. b. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. The charge nurse on the postpartum unit is making assignments. There are a total of 10 adult clients. 3. c. Industry vs inferiority (Select all that apply.). A nurse is adhering to standard precautions while caring for a group of clients. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. (Select all that apply.) Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN?