1. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. This is outside the scope of practice for the LPN/LVN. Which of the following actions should the nurse perform when opening the sterile pack? c. Explore the client's feelings about dietary modifications 5. c. The client's culture The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Incorrect: This prescription is written correctly. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. 1. . Occupational therapist Female client stating she has been raped. 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. This stage involves constructive efforts on the part of the group members Correct: The unlicensed nursing assistant should not turn tube feedings off or on. a. Removing the client's dentures d. Determine if the client uses hearing aids, b. Client who is a diabetic experiencing diabetic neuropathy. Twist at the waist when she moves an object to one side Assist a client to ambulate using a gait belt The supervisor can only send one LPN/LVN to the floor. Client reporting a headache and has a fruity breath. Ask the primary healthcare provider to suggest the best oral care procedure. Alert all off-duty personnel to stand by in case of call- in. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. B. 2. C-section planning discharge, postpartum infection, mastectomy. (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 Perform catheterization when you recognize the urge to void During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 2. Measuring vital signs Administering IV pain medication to a two day post op client. Also, making a surgical bed for the client returning from surgery is a basic procedure. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. d. Discussing intake and output Receive report from the emergency department (ED) on a new client. Evaluate pain relief after narcotic administration. Symbolic communication c. Environment The nurse did not trust the new UAP. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. The nurse has another priority. 4. Right forearm The nurse does not know the skills of the new UAP. b. I can detect the presence of carbon monoxide by a metallic odor 3. c. I will begin upon the client's admission to the facility 2. a charge nurse is making client care assignments for the day. 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. A nurse is preparing to move a client who is only partially able to assist up in a bed. d. Providing information, a. 2. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. The charge nurse should notify the nursing supervisor who will seek additional staff. Client scheduled for a dressing change to foot ulcer. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. Draining the colostomy bag on a client with diarrhea. 3. b. 77. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. A two-hour limit on visits discourages quality time. Documentation is a communication tool for the interprofessional health care team. Which of the following items should the nurse include on the lunch tray? d. What have you done in the past to cope with this issue? Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. d. Complete an incident report, 70. d. I will place a bath seat in my shower to use when I bathe, b. A nurse is caring for a client within the intimate zone of the client's personal space. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. This is likely cholelithiasis, which will need to be checked out. 1, 3 & 5. b. c. Changing a dressing Which of the following should the nurse identify as an interpersonal variable? An experienced person who can research "best practice" regarding the issue is needed. Which client should the nurse assess first? Speak to the UAP to determine what happened with the feeding. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. The primary healthcare provider may have suggestions but this is not the best first action. Speak using his usual tone of voice 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. Phone report to the receiving nurse. b. Which of the following actions should the nurse take? 4. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. c. Review the client's progress toward personal objectives a. a. Which action by an unlicensed nursing assistant would require the nurse to intervene? The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. Relax her abdominal muscles when she lifts an object Discarding the first urine voided by the client starting a 24 hour urine test. d. Assault, b. Select all that apply. A goal for this client is to use proper body mechanics at all times. They are likely to wait for others to initiate conversation Assist a client to ambulate using a gait belt. Client with a T-5 spinal cord injury beginning rehabilitation therapy. Richied5864 Richied5864 . 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. Select all that apply 3. In option #4, we see that the leading zero is missing from the prescription. Select all that apply. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. a. Bathe a client who had an amputation 2 days ago c. Why are you crying? Which actions should be instituted by each unit's charge nurse? a. Which of the following types of communication breakdown does this response represent? 1. c. Face shield Which of the following actions is the priority for the nurse to include in the client's plan of care? Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. 1. 4. 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). 4. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. Decreased or suppressed respiration are priority. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. Incorrect: What seems to be going on with this client? c. Discard any residual gastric contents 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. Offering false reassurance a. c. To determine the client's electrolyte balance d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. 8. Therefore, this client would not be a priority over a client who may be experiencing a MI. 2. a. The best practice committee utilizes current research in their recommendations. 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. c. There is fluid leaking around the insertion site 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Education To confirm the placement of the NG tube 2. When a family member asks how respite care can help, which of the following responses should the nurse provide? Pick up the tray and tell the UAP that they didn't do a good job. c. Review another client's similar surgical experience a. This client needs ongoing monitoring which is within the scope of practice for the LPN. d. Voided 30 mL frequently, 48. c. Gender (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 Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? This schedule may leave some clients too exhausted to visit with family. 2) Assist a client to ambulate using a gait belt. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. a. 2. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. 3. So what is wrong with option #1? Which of the following statements should the preceptor make? Speak to the UAP first and then decide if a between meal supplement is needed. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. D. c. Washes and rinses her hands for 10 seconds, 11. The nurse voices his concern to the charge nurse. A nurse is preparing to obtain a blood specimen from a client by venipuncture. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. Teach the UAP to change surgical dressings. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). 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. b. I will begin once the client's discharge order is written Which clients would be appropriate assignments for the LPN/LVN? Assessing this client and titrating the diltiazem requires the skills of an RN. The women's health charge nurse is making assignments for the next shift. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. a. Remember, pick the killer answer first! Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? 4. Of my three brothers and sisters, my sister Giselle has the best sense of humor. Report of feeling pressure d. Counting radial pulse, 100. Give magnesium citrate 296 mL at 3 PM today. 4. d. Place the tablet directly into a medication cup, 36. 2. 3. 3. Incorrect: The RN is responsible for assessment and evaluation of clients. Where on the body is each type of skin found? C. Review a low-sodium diet for a client who has hypertension. This is an elderly client who is a new admit. 1. a. 3. 3. 2. c. I will cover the catheter so he cannot see it The provider must renew a restraint prescription every 8 hr. The client receives home health care and spends most of his day in a reclining chair. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. 4. c. Shivering A client with exacerbation of COPD reporting dyspnea. (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: This is doing research, which requires the research process be implemented, including appropriate approval. When asking the client about his receptiveness to the transfer A nurse has completed an informed consent form with a client. We see that the temperature is already elevated, which makes us worry that infection is present. Nothing life threatening, but an assessment needs to be made regarding the ulcer. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. b. Discuss the assignment with another LPN. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. A float nurse arrives on the unit to assist in the care of clients for the shift. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. A nurse is teaching a client who has a history of falls about home safety. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Which of the following actions should the nurse take? Correct: The client has the right to be involved in the decision making of their care. c. We administer all medications intravenously to clients in this unit INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. 3. Plan all care to be completed in early morning to allow afternoon for visitation. Both of these clients are terminal. 76. Obtain a client's consent (Select all that apply.) Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. 1. Perform the Heimlich maneuver Select all that apply 4. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. a. 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. 4. Fruity breath. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? A nurse is creating a discharge plan. A client receiving heparin injections for deep vein thrombosis. Wears a gown when entering the room of a client who requires contact precautions c. Malpractice Notify the charge nurse of the observations. one of the licensed practical nurses Get the answers you need, now! This would be out of the UAP's scope of practice. Cystogram reporting burning on urination. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). 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. 4. The nurse should do this when repositioning is needed. Incorrect: This is not completely practical for everyone. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. A nurse is performing care activities for a client in the zone of touch that requires his consent. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? It's just not the right time for me to do this Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. Electric cords behind the furnitrure Explain oral hygiene to a client receiving chemotherapy This includes medication enemas. 3. Which of the following instructions should the nurse include? Compartment syndrome could be developing which can impede circulation and cause nerve damage. 2. b. Initiative vs guilt Place in priority order. A nurse is having difficulty caring for a client due to variables affecting the communication process. d. Counting radial pulse d. Routine acquisition of a urine specimen 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. "The client is weak on the right side, so please assist the client with dressing . Announce the new changes at the monthly staff meeting. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. Assist a client to ambulate using a gait belt b. Drag and Drop the items from one box to the other. Which of the following actions should the nurse take? Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Include any relevant statements the client made about the ulcer, 64. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). The nurse has received the change-of-shift report. Clients over the age of 65 must have a saline lock according to facility policy PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. c. Behaving defensively Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. b. I will come back later and we can talk Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. A nurse caring for a client is using active listening skills. Remember airway, breathing and circulation (ABCs). Which of the following actions indicates that the AP understands the principles of infection control? Determining the client's length of stay This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. What action should the nurse implement first to ensure client safety? Document current functional status assessment c. Leave a nightlight on in the client's room Nurses Report Sheet Template Nicu. 2. The client attempted to climb over the side rails and fell 3. The nurse could definitely be part of the committee. Most of the following sentences contain errors in the use of modifiers and comparisons. b. Select all that apply A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. b. 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. The nurse is responsible for the assessment of all vital signs of post-op clients. d. Establishing the client's secondary medical diagnoses, b. d. Talk with the client's partner, b. d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. 1. A nurse is caring for a client who has a wound infection. What interventions can the nurse delegate to the LPN/VN? Protective Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. a. 2. b. Because the charge nurse observes and weighs . 4. Respite care provides holistic support and care for a client who is terminally ill d. Left forearm, b. Start MgSO4 at 3g/hr IV e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Sit side-by-side with the client 5. Provides safe, effective delivery of patient care in . This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The RN with 10 years' experience pulled from the ER. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Briefly assess every client. 3. Nursing questions and answers. & 5. Select all that apply a. b. Emptying a urinary drainage bag for a client who has pneumonia Complete a client assignment sheet for the oncoming staff. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 208 The abdominal pain is worsening. c. Respite care helps relieve pain and promote comfort This client could be transferred with traction still maintained. which of the following actions should the nurse perform? Select all that apply & 6. 1. Sudden attacks of sleep Gather supplies to prepare room for isolation. 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. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. A nurse is caring for a client who expresses anxiety about his impending surgery. d. Voided 30 mL frequently d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). Licenced practical nurses are a little less educated than registered nurses. Which of the following methods should the nurse plan to use? The option does not say the client is terminal, in a vegetative state, or in a coma. 4. Perform range of motion (ROM) exercises at least 2-3 times daily Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. b. A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Correct. 3. b. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? An Advance Directive includes a Living Will and a Medical Power of Attorney. Correct: This group of clients is primarily med surgical. Normally, red blood cells are flexible and round, moving easily through blood vessels. b. e. Feed a client who had a stroke 3 months ago, 31. Focusing Channel d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 4. The client is reporting anxiety, discomfort, and a feeling of bloating. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. A client post pacemaker insertion, awaiting discharge instructions. b. d. Lean back in the chair, b. a. Incorrect: The nurse is responsible for monitoring a client. Administer tap water enemas until clear at 6 AM. Place the pack on a sterile work surface c. Notifying the provider of physical exam findings They are able to manage tasks related to basic care. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. Once the client is stable, the UAP could perform this task. 2. Although this will require assessment, this client is not the priority at this time. 4., & 5. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. b. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. 1., 2., 3., & 4. 3. d. Motor impairment, 84. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? b. e. an open perineal wound, 92. 1. Which of the following instructions should the nurse give to the client prior to the procedure? This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. d. Social conversation, a. A list of current medications is sent to the facility. d. principal. Which of the following pieces of PPE should the nurse remove first? 2. What is the appropriate assignment? Which of the following findings associated with urinary retention should the nurse expect? 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. Nurses dependent on drugs or alcohol can harm clients. 1. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Write N next to the nonessential clauses and E next to the essential clauses. The charge nurse is making client assignments for a neuro-medical floor. The surgeon initially prescribes a clear liquid diet. The nurse should not be assigned to provide care if impairment is suspected. Making client care assignments As the RN charge | Chegg.com Science Nursing Nursing questions and answers Making client care assignments As the RN charge nurse, you are preparing to make assignments for the oncoming shift in the medical-surgical unit. a. a. 3. 3. Incorrect. The nurse is reviewing some clients' prescriptions. Correct: Hot water may damage dentures so intervention is needed. This is normal for clients with hemorrhoids. 1. a. a. Elicit info from the client a. Broth Which of the following actions should the nurse take regarding informed consent? 1. A nurse who is on hormone replacement therapy. A nurse is caring for a client who is postoperative following abdominal surgery. Incorrect: The nurse cannot assign teaching to the UAP. 4. 3. The RN with 2 weeks' experience on the postpartum unit. 3. Irrigate a client's ear canal. Limit the client's fluid intake in the evening A nurse is caring for a client who has emphysema and has difficulty with mobility. 4. What options would be appropriate for the nurse to take? b. a. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). 3. In order to reorganize staffing, the nurse manager should initiate which action first? Ask the charge nurse to evaluate the intervention. 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. 3. 1. 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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