a charge nurse is making client care assignments

4. A nurse is discussing the norming stage of the group development process with a student nurse. 2. What is the major histological difference between thick and thin skin? A nurse is caring for a client who is postoperative following abdominal surgery. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Select all that apply Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Client with ureterolithiasis who requires frequent PRN pain medication. 4. Performing passive range of motion (ROM) on the client with right sided paralysis. - Assisting a client to ambulate using a gait belt. 4. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. What should the nurse do first? (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 Electric cords behind the furnitrure Which of the following actions is the nurse's priority? b. 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. Reach around the pack and open the top flap away from the body A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. C. Review a low-sodium diet for a client who has hypertension. Incorrect: The charge nurse does not have to assess every client. 3. There may be a good reason that the tray was not served. The charge nurse might not have realized all the responsibilities of taking this team of clients. Which of the following findings associated with urinary retention should the nurse expect? Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? The last client would be the one needing dietary education. 5. Encourage clients and families to develop mutually appropriate visitation times. c. Review the client's progress toward personal objectives Select all that apply Incorrect: This would unnecessarily alarm the clients. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). Correct: If suspicious behavior occurs, it is important to keep careful, objective records. 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. 1) Bathe a client who had an amputation 2 days ago. This protein is released by cells in the stomach. Incorrect: The nurse cannot assign teaching to the UAP. Select all that apply Right forearm Which clients could be assigned to an LPN? A nurse is caring for a client who expresses anxiety about his impending surgery. There is a trailing zero after the prescribed dose. Feedback The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. 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. Clients over the age of 65 must have a saline lock according to facility policy a. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Perform the Heimlich maneuver Incorrect: This again is assessment which is the role of the RN only. Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. This schedule may leave some clients too exhausted to visit with family. Correct: Hot water may damage dentures so intervention is needed. d. When asking if the client took his medications this morning, 82. The nurse has just completed a 12 hour shift. 4. Incorrect: This client is exhibiting early signs of increased intracranial pressure. e. The urge to move the legs when trying to sleep, 66. 1., 2., 4., & 5. Once the client is stable, the UAP could perform this task. d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. 4. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Question: A charge nurse is making client care assignments. Only a plain enema or soap enema can be given by the UAP. Which of the following types of torts has the nurse committed? 3. 2) Assist a client to ambulate using a gait belt. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. d. Perception Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. 4. c. Face shield A nurse just back from maternity leave. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. c. I will cover the catheter so he cannot see it A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. a. 1, 3 & 5. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. Have a pen and paper handy c. Check to see if the suction equipment is working b. Which preoperative prescription should the nurse question? 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. This could cause a medical emergency. What is the best care assignment for this client? A nurse is teaching a client who has a history of falls about home safety. Which action should the nurse interrupt the UAP from performing? 6. Call the client's provider Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Offer to take one of the clients. a. Shakes the soiled linen to remove any toilet paper remnants A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Yes! d. Voided 30 mL frequently, 48. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). "The client is weak on the right side, so please assist the client with dressing . So what is wrong with option #1? b. c. I will complete the smoking cessation program I started Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Incorrect: The nurse retains the responsibility for the delegated task. D. (Select all that apply.) a. Clarifying 2. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. The nurse has received the change-of-shift report. Rewrite each incorrect sentence to correct the error. 1. 2. Assist a client to ambulate using a gait belt Client prescribed antibiotics for cystitis. Narrative interaction 1. If you give the magnesium citrate, which is a laxative, what will happen? Prepare a list of clients who could quickly be discharged or transferred. 2. Client diagnosed with Guillain-Barre' who is receiving ventilator support. leadership management of care nurse on unit is providing care for group of clients. A nurse is prioritizing care for two clients at the start of the shift. Allow the UAP to work without supervision. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. Following the teaching, the nurse asks the client to describe one physical effect. 3. 3. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Ask the RN why the assignment is too heavy. 3. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Which of the following actions should the nurse take? A nurse who is 10 weeks pregnant. 5. 3. 2. Checking capillary refill beneath the client's fingernail They have found my address and are coming for my family!" 2. b. 3. A charge nurse is making client care assignments. 2. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Incorrect: Informing is the same thing as teaching. 2. b. A skill for which the ap has received instruction the - Course Hero Which of the following approaches should the nurse use when using confrontation? Elderly client admitted 30 minutes ago with reports of constipation for four days. 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. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. 4. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). A nurse instructs a female client about collecting a midstream urine sample. Which of the following tasks should the nurse delegate to assistive personnel (AP)? 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. Each ROM movement should be repeated 5 times during the session. Collecting I & O totals for unit clients at the end of shift. b. Incorrect: Atrial fibrillation places the client at risk for blood clots. 4. A client requesting assistance packing his belongings for discharge later today., Incorrect: The client does need to have food; however, there is another action that should be performed first. The client states, "I am so nervous about what the doctor might find during the test." A client with atrial fibrillation currently on a diltiazem drip. a. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. Confrontation should occur in the presence of a charge nurse or supervisor. 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. 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. A client receiving heparin injections for deep vein thrombosis. a. a. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. d. Transporting a cerebrospinal fluid specimen to the lab Soaking the dentures in hot water Which of the following RNs should not be assigned to this baby? What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? Phone report to the receiving nurse. Where on the body is each type of skin found? Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. 2. Which of the following activities should the nurse perform in this zone? Ambulating a client who is 2 days post vaginal hysterectomy A medical-surgical LPN has been sent to a short-staffed pediatric unit. Delegate 2 nurses to work with the client. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Lumbar puncture reporting a headache. Irrigate a client's ear canal. a.) Currently, your census is 11, with one empty bed. 2. 5. a. c. Explore the client's feelings about dietary modifications Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Currently, your census is 11, with one empty bed. b. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. Now, in Option #2, we see a dangerous prescription. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. A practical guide to making patient assignments in acute care 2. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. 2. 4. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. b. a. Gloves which client would be an appropriate care assignment for this lpn? 4., & 5. The client attempted to climb over the side rails and fell b. Which of the following indications should the nurse include? Select all that apply 3. Which referral would most likely be appropriate for the nurse to make? The facility has insurance that will cover malpractice litigation 2. c. Changing a dressing, 78. b. 3. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. 1. 4. The charge nurse on the postpartum unit is making assignments. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. 2. c. Hand-off technique Based on the information provided in report, which client condition should be the nurse's priority? b. What is the best first action for the nurse to take in order to achieve this goal? The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. It happened so long ago - just get over it!" e. Dysuria, 49. Nothing life threatening. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. c. To determine the client's electrolyte balance UAPs can assist with elimination and are taught how to measure output. & 3. Alert all off-duty personnel to stand by in case of call- in. Nurses dependent on drugs or alcohol can harm clients. Fruity breath. The abdominal pain is worsening. For which of the following tasks should the nurse wear protective eye equipment. 1. Explore the client's feelings Encourage the client to use self-exploration 3. An Advance Directive includes a Living Will and a Medical Power of Attorney. b. Donation costs are the responsibility of the donor's family and estate Increased insulin production Incorrect: The nurse is responsible for monitoring a client. Ask the float nurse, "Have you been drinking?" The nurse asks why the client needs to know this. Documentation of what occurred, and the client's assessment is required in the nurse's notes. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Obtain a bedside commode for the client's use Select all that apply. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Only the state Board of Nursing can legally determine the LPN's scope of practice. Warm the feeding solution to the body temperature A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. A nurse is admitting a client from a long-term care facility. 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. b. Irrigate the wound with an antiseptic prior to obtaining the specimen 6. The surgeon initially prescribes a clear liquid diet. c. Contact This stage involves constructive efforts on the part of the group members The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Include any relevant statements the client made about the ulcer, 64. d. Let's wait until tonight to see if he continues his behavior, 63. Report of feeling pressure A client has been admitted with folic acid deficiency anemia. 5. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. This could indicate a worsening of this client's condition. 4. I'm drinking plenty of fluids." 4. Based on this information,what should the nurse do? NURSING ASSIGNMENT- delegation in the workplace | Studymonk Aplastic anemia is a rare but serious condition. To confirm the placement of the NG tube The client then states, "I have changed my mind and do not want to have the procedure done." 4. 1. a. Solved 77. The nurse in a long-term care facility is making - Chegg A nurse is planning to discharge a client who has quadriplegia to his home. (SATA) -Bathing a client who had an amputation 2 days ago. 4. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. c. Washes and rinses her hands for 10 seconds, 11. Which of the following of Erikson's developmental stages should the nurse consider in the planning? c. I will place an area rug at the entry of my bathroom Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. 1. a. b. I'll use the cleansing wipes from the front to back 2. Sit side-by-side with the client (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. 1. Select all that apply. b. Incorrect: The RN is responsible for teaching. d. I will place a bath seat in my shower to use when I bathe, b. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. 2. Select all that apply Inform the client of the need to avoid irritants such as carbonated beverages. Changing a colostomy bag. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Provide a between meal supplement to the client. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. What is the most appropriate action by the charge nurse? Which of the following statements by the nurse would provide UAP with the best directions about an assignment? Which of the following actions should the nurse perform when opening the sterile pack? c. Hallucinations at the onset of sleep 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. a. This is normal for clients with hemorrhoids. Which action by an unlicensed nursing assistant would require the nurse to intervene? b. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Which of the following findings should the nurse expect? 4. Which of the following info should the nurse include? 4. Serve milk products separately from meals Perform range of motion (ROM) exercises at least 2-3 times daily 2. 2. 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. Speak to the UAP to determine what happened with the feeding. Which of the following actions should this nurse take? Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 2. Problems in Delegation: A Busy Day on the Floor - Quizlet Correct: The client who has a cast and requires pain medication is a stable and predictable client. 4. 1. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. An LPN/VN has been floated to the emergency room following a chemical plant explosion. Aplastic Anemia Support Group. 4. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. a. I'll sit with my knees lower than my hips Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 1. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. a. 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. 1. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. We do not know the extent of her injuries based on what the option tells us. 4. c. There is fluid leaking around the insertion site The charge nurse is making client assignments for a neuro-medical floor. 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. a. I'll apply ankle to my ankle today and tomorrow c. Use intermittent eye contact ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. The best practice committee utilizes current research in their recommendations. e. Feed a client who had a stroke 3 months ago, 31. Temporary urinary retention Pernicious Anemia Society These are appropriate tasks for an UAP to complete. 5. The nurse who made the medication error should take which of the following actions first? When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? The nurse would then start the 24 hour urine once the 1st void has been discarded. Involve the client in their plan of care. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. b. b. Urinary frequency for several days This is a diabetic clinic. c. 214 Have another nurse guard the medication preparations until the nurse returns Start MgSO4 at 3g/hr IV The option does not say the client is terminal, in a vegetative state, or in a coma. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. Select all that apply. Which of the following instructions should the nurse give to the client prior to the procedure? In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. This would be out of the UAP's scope of practice. Incorrect: This group of clients needs specific teaching. Review a low-sodium diet for a client who has hypertension. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. This service focuses on teaching the primary caregiver to meet the client's needs Battery This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. Incorrect: What seems to be going on with this client? a. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP.

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