a charge nurse is making client care assignmentsa charge nurse is making client care assignments

The nurse asks why the client needs to know this. Licenced practical nurses are a little less educated than registered nurses. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. 1. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Provides safe, effective delivery of patient care in . 2) Assist a client to ambulate using a gait belt. d. Place the tablet directly into a medication cup, 36. d. Do you think crying will help? one of the licensed practical nurses Get the answers you need, now! LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Document what the nurse believes was the cause of the ulcer development Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Limit the client's fluid intake in the evening (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. Also, making a surgical bed for the client returning from surgery is a basic procedure. A nurse is caring for a client who is immobile. 2. 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. I will inspect my crutches everyday for signs of wear a. To remove gastric acid that might cause dyspepsia Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. 3. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Select all that apply. e. Feed a client who had a stroke 3 months ago, 32. 1. c. I will complete the smoking cessation program I started INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. The expected standard of care was strict bed rest), 96. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Checking capillary refill beneath the client's fingernail d. 216, 22. 2. Incorrect: The RN is responsible for assessment and evaluation of clients. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Temporary urinary retention Currently, your census is 11, with one empty bed. 3. Explain oral hygiene to a client receiving chemotherapy 6. a.) d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. The client's self-report of pain severity Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Plan all care to be completed in early morning to allow afternoon for visitation. Documentation is a communication tool for the interprofessional health care team. A two-hour limit on visits discourages quality time. Which of the following actions should the nurse take? Showing disapproval Assist a client to ambulate using a gait belt. c. Gender The best practice committee utilizes current research in their recommendations. b. The client is apparently stable and does not require any advanced assessment skills or specialized care. b. Urinary frequency for several days a. 4. They are likely to wait for others to initiate conversation The primary healthcare provider may have suggestions but this is not the best first action. c. Depression 4. 3. Drag and Drop the items from one box to the other. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. a. 3. b. which of the following actions should the nurse perform? What is the appropriate assignment? c. Provide the client with a diet high in protein b. The client reports constipation for 4 days which may be an indication of worse problems. Gather and apply dressings to open wounds. 1., 4., & 5. 5. b. I'll rewrap my ankle starting from the knee down So, now you must decide which of these high priority clients should be seen in what order. Make nursing assignments appropriate to the skill level . Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. c. Complete an incident report a. Each state BON differs in that also some have treatment programs they administer themselves. Documentation of what occurred, and the client's assessment is required in the nurse's notes. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 4. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Which of the following statements should the nurse identify as an indication that the client needs further teaching? Which referral would most likely be appropriate for the nurse to make? a. Which of the following statements by the student indicates understanding of the discussion? c. Hallucinations at the onset of sleep He charge nurse is making client care assignments for the evening shift. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The best practice committee works to improve clinical practice based on current research. a. I will wear gloves when removing food from the freezer All these clients have a GI problem. d. Counting radial pulse, 100. 1., 2., 3., & 4. 1. A nurse caring for a client is using active listening skills. Correct: Traction should never be relieved without a primary healthcare provider's prescription. c. Offering false reassurance a. 4. 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. 1. 4., & 5. 4. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. Which clients could be assigned to an LPN? Client diagnosed with inoperative brain tumor who is confused. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. When determining if the client is eating a well-balanced diet Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. The nurse should not lecture, scold or argue with the float nurse. 4. b. 1. Client one day post kidney transplant. Which of the following actions should the nurse take? This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. 2. 1., 2., 4., & 5. c. I'll need to shave the hair off the skin where I place the electrodes 4. 2. c. I will place an area rug at the entry of my bathroom Notify clients that the disaster plan has been put into effect. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) c. Holds the soiled linen against her body while carrying it to the linen bag Select all that apply. Which of the following responses should the nurse make? 4. A client post pacemaker insertion, awaiting discharge instructions. Bargaining A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? d. Mask, 83. 4. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. a. Hypotension Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. c. Measurement of residual urine after urination b. 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). Transfer essential medical record to the receiving facility. Which of the following actions is an example of a violation of confidentiality? 4. a. Bathe a client who had an amputation 2 days ago 1. 4. a. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Which of the following actions is the nurse's priority? Of my three brothers and sisters, my sister Giselle has the best sense of humor. This service focuses on teaching the primary caregiver to meet the client's needs Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. with this question, the nurse is using which of the following communication techniques? This stage is when testing occurs to identify boundaries of interpersonal behaviors 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. d. Message, 67. 2. 3. Which of the following pieces of PPE should the nurse remove first? 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. A client with diabetes admitted for debridement of a foot ulcer. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. An adolescent client post appendectomy reporting pain. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. 6. 1. Select all that apply. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. a. d. Lean back in the chair, b. Vital sign measurement a. Correct. 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. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Allow families unlimited visitation around the clock to meet their schedules. a. Auscultating heart sounds The surgeon initially prescribes a clear liquid diet. A nurse is caring for a client who has a hip fracture that requires surgical repair. 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. c. I should purchase a carbon monoxide detector for my home Correct: The unlicensed nursing assistant should not turn tube feedings off or on. b. This would be an acceptable task to assign to the UAP. Semi-formed stools are great news! Start MgSO4 at 3g/hr IV Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. The nurse is using which level of communication at this time? Provides day to day direction and supervision to assigneddirect patient care staff . Changing the subject Administering 3 g/hr IV of morphine would be extremely dangerous. UAPs can assist with elimination and are taught how to measure output. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. b. Massage any bony prominences to promote circulation A nurse is preparing a sterile field. a. Warm the feeding solution to the body temperature Which of the following actions should the nurse take prior to administering the tube feeding? Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding). Which of the following findings should the nurse expect? Nurses dependent on drugs or alcohol can harm clients. a. 3. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Measure urine output when client voids. Speak to the UAP first and then decide if a between meal supplement is needed. Airborne The client would develop severe cramping. Removing the abdominal dressing Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? Turn on local news for up-to-date information on the train derailment. b. 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. Photo comes from the Greek word for light. 3. 3. 3. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. 3. The client states, "I am so nervous about what the doctor might find during the test." 1. Remember airway, breathing and circulation (ABCs). The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Therefore, this client would not be a priority over a client who may be experiencing a MI. The third client that should be sent back for treatment is the female client stating she has been raped. 4. 4. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. Which client should be assigned to the most experienced nurse? butter, which contain 16 g of protein, 7 g of carbohydrates, 4. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. 4. 5. b. I will keep the fluorescent ceiling light on in my room at night It can result in muscle spasm and tissue damage. Electric cords behind the furnitrure Which of the following actions should the nurse take to assist the client with feeding? Send a day's worth of medications with the client to the receiving facility. Removing the client's dentures a. Witness the client's signature (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 c. I will make sure my visitors smoke outside b. Which of the following is the priority action by the nurse? A nurse is orienting a new assistive personal (AP) to the unit. A charge nurse is making client care assignments. b. A nurse is caring for a client who has limited hand movement. 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 nurse is caring for a client who has emphysema and has difficulty with mobility. 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. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. 4. a. Thus, the tasks involve successful management of the charge nurse's responsibilities. Select all that apply. Select all that apply b. eminent 2. 1, 3 & 5. Which task would be appropriate for the nurse to assign to an LPN/VN? Simply accept the assignment since overtime is mandatory. Correct. Incorrect: It is out of the UAP's scope of practice to administer medication. c. Raised toilet seats 4. This service began with the client's admission to the hospital, 18. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. a. The charge nurse needs additional information to make a decision. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. Correct: Communication is important in delegation, as is follow-up. Decide which choice fits best in the blank. The nurse voices his concern to the charge nurse. 5. 6. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 1. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Most of the following sentences contain errors in the use of modifiers and comparisons. 2. e. Dysuria, 49. Which of the following statements should the nurse make? This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. A charge nurse is making client care assignments. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. A nurse is teaching a client about the physical effects of chemotherapy. The nurse received a client following surgery 8 hours ago. An increased temperature will have a direct effect on the brain's metabolism and function. An adult (18 years or older) can create an advanced directive. Which of the following actions should the nurse take? Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. 3. b. Wash the area of the puncture thoroughly with soap and water The client can indicate desire for Do Not Resuscitate (DNR). c. Malpractice The surgeon initially prescribes a clear liquid diet. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. It is not a routine task. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 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). (Select all that apply.) There is a possibility that a hypothermia blanket may be prescribed. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? c. One nurse lifting the client's legs as the client uses a trapeze bar 3. the nurse responds, "don't worry, no one will harm your family." 1. Only the state Board of Nursing can legally determine the LPN's scope of practice. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 3. Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. a. Did you recognize ureterolithiasis as "kidney stones"? Which of the following approaches should the nurse use when using confrontation? This client needs ongoing monitoring which is within the scope of practice for the LPN. e. an open perineal wound, 92. 4. b. Assigning tasks to an AP A nurse receives a client care assignment from the charge nurse that he believes is unfair. Normally, red blood cells are flexible and round, moving easily through blood vessels. 1. b. b. 2. Incorrect: Atrial fibrillation places the client at risk for blood clots. Encourage client to express grief related to loss of independence. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? M2.4: Making Client Care Assignments-GECC As the RN charge nurse, you are preparing to make assignments for the oncoming shift on the medical- surgical unit. Who should the nurse see first? Provide an adaptive feeding device for the client A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 4. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Observe the client before taking further actions b. Emptying a urinary drainage bag for a client who has pneumonia Which of the following statements by the nurse would provide UAP with the best directions about an assignment? Notify the surgeon that the client wishes to withdraw informed consent for the procedure The nurse considers various ideas submitted by team members. 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. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. a. 2. Which of the following communication techniques should the nurse use during this phase? If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. The supervisor can only send one LPN/LVN to the floor. Client with chronic emphysema experiencing mild shortness of breath. 4. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Nothing life threatening, but an assessment needs to be made regarding the ulcer. d. Explain oral hygiene to a client receiving chemo This client is stable and predictable. Left upper forearm c. When asking the client how he completes his ADLs Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. c. Rephrase statements the client does not hear 1. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. It is quicker to administer medications intravenously in the hospital Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? The client attempted to climb over the side rails and fell a. 3. The nurse did not trust the new UAP. 3. Dexlansoprazole 30 mg PO daily. The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels.
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