a charge nurse is making client care assignments

It's just not the right time for me to do this Which of the following findings indicates that the client is meeting this goal? c. Gender b. No! a. Focus on the client's present circumstances instead of his personal stories 2. 3. 4. c. Include intact skin at the wound edges in the culture 4. 4., & 5. Ask the RN why the assignment is too heavy. d. Motor impairment, 84. 3. Irrigate a client's ear canal. 2. An increased temperature will have a direct effect on the brain's metabolism and function. a. Client scheduled for breast reconstruction after mastectomy. Nothing will get passed the complete blockage. 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. Request a prescription for a medication to ease the client's anxiety 3. 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. b. Providing hygiene care to a client who is HIV positive A nurse is caring for a client who frequently attempts to remove his IV catheter. b. eminent A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Notify the primary healthcare provider. 3. a. b. a. a. a. Asking for an explanation Correct: The unlicensed nursing assistant should not turn tube feedings off or on. Inform the client of the need to avoid irritants such as carbonated beverages. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Client to receive dietary education. Nursing questions and answers. a. Which of the following actions should the nurse take regarding informed consent? Ask for any staff objections to rearranging work hours. Correct: This group of clients is primarily med surgical. Which of the following indications should the nurse include? Transfer essential medical record to the receiving facility. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department Battery A client diagnosed with rheumatoid arthritis needing discharge teaching. a. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. e. Suctioning a client's new tracheostomy tube, 93. c. I will make sure my visitors smoke outside -Review a low-sodium diet for a client who has HTN The client attempted to climb over the side rails and fell A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. In the following sentences, circle each incorrectly used lowercase letter. 4. 1. Tenderness over the symphysis pubis 6. c. Do not eat or drink anything the morning of the test Evaluate pain relief after narcotic administration. Only the state Board of Nursing can legally determine the LPN's scope of practice. The client post PEG placement is stable. Allow the UAP to work without supervision. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. c. Environment d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. 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. 5. 4. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Gown 4. b. d. Determine if the client uses hearing aids, b. Assessing this client and titrating the diltiazem requires the skills of an RN. (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 b. 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. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. 1. The charge nurse on the postpartum unit is making assignments. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. a. d. What have you done in the past to cope with this issue? c. Raised toilet seats d. Voided 30 mL frequently, 48. c. Hallucinations at the onset of sleep, 65. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The client asks the nurse, "Why do I need that? As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. Because the charge nurse observes and weighs . A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following client statements indicates an understanding of the procedure? Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. Allow families unlimited visitation around the clock to meet their schedules. 3. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? c. I will inspect my crutches everyday for signs of wear b. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. The charge nurse might not have realized all the responsibilities of taking this team of clients. What action should the nurse take after mistakenly administering the wrong medication? Removing the client's dentures d. I will begin once the client's insurance company approves discharge coverage, b. What task would be best to assign to the LPN/LVN? d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. a. Which of the following instructions should the nurse include? Temporary urinary retention This is an appropriate and safe action for the unlicensed nursing assistant to do. c. Leave a nightlight on in the client's room A family member requests that the nurse apply restraints. Incorrect: This is not completely practical for everyone. The best practice committee utilizes current research in their recommendations. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. Initiate oxygen and IV lines as needed. For which of the following actions should the nurse intervene? Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. 3. d. Mask, 83. 2. Places the soiled linen in the floor before bagging it The nurse is using which level of communication at this time? 5. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 3. _________________ (magnanimous), a. generous The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Although this will require assessment, this client is not the priority at this time. c. They tend to use more verbal communication A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. The facility has insurance that will cover malpractice litigation d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Incorrect: The RN is responsible for teaching. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. The nurse is caring for four clients. 3. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. (SATA) -Bathing a client who had an amputation 2 days ago. c. The client's culture Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Assign a nursing assistant to help the client with self-care activities. The last client would be the one needing dietary education. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Removing the abdominal dressing All these clients have a GI problem. b. 3. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). a. b. a. Gloves It is quicker to administer medications intravenously in the hospital one of the licensed practical nurses Get the answers you need, now! Each state BON differs in that also some have treatment programs they administer themselves. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. b. Which of the following statements by the student indicates understanding of the discussion? 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. 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? Incorrect: The RN is responsible for assessment and evaluation of clients. A nurse is performing care activities for a client in the zone of touch that requires his consent. which of the following actions should the nurse perform? Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. c. Blood-tinged urine Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. Provide positive feedback to the UAP. Besides yourself, there are the following staff: Your unit has 12 beds. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Which client would be appropriate for the RN to assign to the LPN? 4. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. The RN with 8 years' experience in the Intensive Care Unit. b. 1. Client diagnosed with Guillain-Barre' who is receiving ventilator support. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Teaching insulin self administration to a diabetic client. a. c. Contact 1. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. This determination is needed to assure client safety is being considered. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. c. Inform the surgical team to cancel the client's surgery A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 4. Encourage the client to use self-exploration Notify the charge nurse of the observations. This is outside the scope of practice for the LPN/LVN. A nurse is assessing a client who is experiencing prostatic hypertrophy. Client with cast to right leg requiring pain medication. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. In order to reorganize staffing, the nurse manager should initiate which action first? b. I will begin once the client's discharge order is written d. Providing information, a. Turn on local news for up-to-date information on the train derailment. Elderly clients have special fluid and electrolyte issues after a fall. Plan all care to be completed in early morning to allow afternoon for visitation. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. 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). Which of the following types of torts has the nurse committed? Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 4. c. Hand-off technique This would be out of the UAP's scope of practice. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. The nurse did not trust the new UAP. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. The key word in the stem is first. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. A client who is disoriented and awaiting transfer to a long-term care facility. Currently, your census is 11, with one empty bed. Ask client if they are eating small, frequent meals. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. a. Broth 2. & 4. Well, do you see the q.d.? 7. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. 4. 6. b. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. Following a large hurricane, multiple clients arrive at the emergency room for treatment. Perform range of motion (ROM) exercises at least 2-3 times daily Select all that apply Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. A nurse is caring for an older client who is at risk for skin breakdown. A nurse is teaching a client who has a history of falls about home safety. C. Review a low-sodium diet for a client who has hypertension. Ask the client to perform a return demonstration of insulin injection Which of the following responses should the nurse provide? Right forearm However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Announce the new changes at the monthly staff meeting. Select all that apply b. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. Documentation of what occurred, and the client's assessment is required in the nurse's notes. Bargaining c. We administer all medications intravenously to clients in this unit 3. A nurse is developing a plan of care for a client who practices Islam. c. Discard any residual gastric contents b. c. Distended bladder Simply accept the assignment since overtime is mandatory. d. Social conversation, a. c. Explain the risks and benefits of the procedure 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 has just finished a wound irrigation for a client who requires contact precautions. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Empty the drainage bag at least every 8 hrb.) Determining the client's length of stay Client who has multiple injuries from a motor vehicle accident. 3. A nurse is filling out an incident report after finding a client lying on the floor. c. Lock the medication in a room and finish preparing it after returning from the emergency Incorrect: The charge nurse does not have to assess every client. Have another nurse guard the medication preparations until the nurse returns 2. One important aspect is encouraging the flow of ideas between management and staff members. Which of the following actions is the nurse's priority? 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. Estimate the number of Calories in two tablespoons of peanut Which nurse should be assigned to care for this client? Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? butter, which contain 16 g of protein, 7 g of carbohydrates, Which of the following communication techniques should the nurse use during this phase? d. Remove tea and coffee from meal trays, b. c. I'll bear weight on my ankle for 10 minutes every hour The best practice committee works to improve clinical practice based on current research. a. I'll provide more stimulation in his environment b. Negligence The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. b. I will bear the weight of my body on my hands Speak to the UAP first and then decide if a between meal supplement is needed. When staff do not feel vested in any new process, there is a sense of underappreciation. This client needs careful monitoring and specialized care. c. Decreased sodium excretion Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? 3. They are likely to wait for others to initiate conversation Thus, the tasks involve successful management of the charge nurse's responsibilities. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client. 1. The client must understand the need for restraints c. Hold an object away from her body as she lifts it b. 2. Sudden attacks of sleep A medical-surgical LPN has been sent to a short-staffed pediatric unit. a. Shakes the soiled linen to remove any toilet paper remnants c. Helping the client into the shower 2. 3. The third client that should be sent back for treatment is the female client stating she has been raped. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. c. Nonfat milk Airborne c. Check to see if the suction equipment is working c. Foot 5. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. A nurse is caring for a client who is postoperative following abdominal surgery. b. 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. Report of feeling pressure a. I'll sit with my knees lower than my hips Drag and Drop the items from one box to the other. 1., 2., 3., & 4. 3. Schedule visiting times in two-hour increments so clients are not overwhelmed. The unit is short one staff member and will receive a nurse from the medical surgical unit. A nurse is completing discharge teaching with a client. Notify clients that the disaster plan has been put into effect. Lisinopril 20.0 mg PO daily The charge nurse's best response is to first obtain the needed information to make the best decision. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Nothing life threatening, but an assessment needs to be made regarding the ulcer. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. He charge nurse is making client care assignments for the evening shift. 5. Assist a client to ambulate using a gait belt a. Correct: The medical nurse can be assigned to this client. d. Reduced blood viscosity, a. Auscultating heart sounds a. Bathtub with rails 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. e. Throw rugs, 40. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. a. 2. 3. 3. b. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Select all that apply Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? a. Hypotension Electric cords behind the furnitrure Obtain a client's consent 4. a. Select all that apply. 2. This is likely cholelithiasis, which will need to be checked out. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. b. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? A list of current medications is sent to the facility. Nothing life threatening. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. 1. Client one day post kidney transplant. Incorrect: It is out of the UAP's scope of practice to administer medication. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. 5. 1. 4. b. I'll use the cleansing wipes from the front to back Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. c. Tie linen bags securely at the top A nurse just back from maternity leave. c. Open the right flap with the left hand The nurse also needs to be aware of the color and amount of urine voided. The RN with 10 years' experience pulled from the ER. 3. Relief of urinary retention d. Highly concentrated urine, 91. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? Remind the client to tell the nurse when he has to urinate When determining if the client is eating a well-balanced diet d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. D. Select all that apply Which action by an unlicensed nursing assistant would require the nurse to intervene? Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. a. Auscultate breath should at least ever 2 hr b. Massage any bony prominences to promote circulation The nurse should do this when repositioning is needed. 4. Comatose client with end stage chronic obstructive pulmonary disease. c. Palpating for pedal edema Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. The primary healthcare provider may have suggestions but this is not the best first action. b. Emptying a urinary drainage bag for a client who has pneumonia A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. b. I'm so sorry to hear about this This situation is considered an external disaster which means the hospital will be expecting multiple victims. The nurse has been assigned four clients. In what order should the emergency department triage nurse send these clients to a room for treatment? c. Offer the client personal thoughts and beliefs 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. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Invite staff to contribute ideas on scheduling changes. This action is a defensive intervention, and does not address the quarrelsome behavior. Refuse the overtime assignment, being prepared for disciplinary action. 3. Following the teaching, the nurse asks the client to describe one physical effect. 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. This task cannot be delegated to the LPN/LVN. Which of the following actions should the nurse take? What is the best care assignment for this client? Reach around the pack and open the top flap away from the body, 53. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. b. I'll do exercises that strengthen my abdominal muscles In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Both of these clients are terminal. 3. Use the tablet's packaging to pick it up from the counter Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? 6. a. 3. 2. Discuss the competency of the surgeon A nurse caring for a client is using active listening skills. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. 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 client is apparently stable and does not require any advanced assessment skills or specialized care. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 2. Determine caregiver's stress level and coping strategies. 3. 1., 2., 3., & 4. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. 3. 4. During exacerbation, the client will have many diarrhea stools. In which harmonic number n is the string vibrating? 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. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. "The client is weak on the right side, so please assist the client with dressing . b. 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. c. Review a low-sodium diet for the client who has hypertension So what is wrong with option #1? Incorrect: This again is assessment which is the role of the RN only. 2. A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following findings should the nurse identify as a safety risk? Correct. 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.

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