A nurse is teaching a client about the physical effects of chemotherapy. c. Inform the surgical team to cancel the client's surgery 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. A nurse is assessing a client who is experiencing prostatic hypertrophy. The spouse can rescind the Advance Directive if the client becomes unresponsive. Well, do you see the q.d.? A nurse is caring for a client who is postoperative following an appendectomy. This documentation should go to your manager. c. Industry vs inferiority Everything will be okay e. Throw rugs, 40. Assign a nursing assistant to help the client with self-care activities. It can result in muscle spasm and tissue damage. b. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. Irrigate a client's ear canal. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? A nurse is discussing the norming stage of the group development process with a student nurse. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? }? benefactor of the world. The RN with 8 years' experience in the Intensive Care Unit. 3. 2. Which of the following info should the nurse include? Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. The cause of the fall may be cardiac, but the question does not indicate this. Incorrect: Informing is the same thing as teaching. A nurse is caring for a client who expresses anxiety about his impending surgery. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? c. The client was restless and trying to get out of the bed all evening Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. the nurse responds, "don't worry, no one will harm your family." Observe the client before taking further actions Which of the following is the priority action by the nurse? (Select all that apply.) d. Highly concentrated urine, 91. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. A nurse is preparing to obtain a blood specimen from a client by venipuncture. Incorrect: This is not completely practical for everyone. 3. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. e. The urge to move the legs when trying to sleep, 66. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. The charge nurse is planning the staff assignments for the clients on a neurological unit. Which of the following actions should the nurse take? A nurse is assessing a client who has narcolepsy. Ask the primary healthcare provider to suggest the best oral care procedure. d. Water heater temp 54.4 C (130 F) b. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. b. 3. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. a. 2. Suggest splitting the shift with another nurse. Focusing Which of the following RNs should not be assigned to this baby? d. Decreased calcium excretion, c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown), 27. In which situation should the nurse consult the client's advanced directive? Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 1. Which of the following actions is the priority for the nurse to include in the client's plan of care? c. Notifying the provider of physical exam findings Measuring vital signs 1. Once the client is stable, the UAP could perform this task. 2. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Protective 5. There will likely be both physical and emotional injury that needs attention, which places this client third. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. 2. 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. Incorrect: The RN is responsible for assessment and evaluation. Prior to turning feeding back on, tube placement needs to be verified. Which client would be appropriate for the RN to assign to the LPN? A client with COPD complaining of shortness of breath on exertion. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". Obtain a bedside commode for the client's use This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). a. Auscultating heart sounds Which of the following interventions should the nurse include? Incorrect: Teaching is outside the scope of practice for the LPN/LVN. A nurse is filling out an incident report after finding a client lying on the floor. b. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. (Select all that apply.). Nursing questions and answers. Currently, your census is 11, with one empty bed. 4. 2. 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? I am feeling much better since my discharge from the hospital and I think my kidneys are working again." 3. The nurse should not be assigned to provide care if impairment is suspected. Dexlansoprazole 30 mg PO daily. 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. Following a large hurricane, multiple clients arrive at the emergency room for treatment. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. c. I will cover the catheter so he cannot see it Incorrect: This again is assessment which is the role of the RN only. Plan all care to be completed in early morning to allow afternoon for visitation. The supervisor can only send one LPN/LVN to the floor. Call the client's provider Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. 3. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Notify the primary healthcare provider. This referral would be appropriate. 4. What is the best care assignment for this client? 1. b. The report should contain consequences. This task cannot be delegated to the LPN/LVN. What is the best first action for the nurse to take in order to achieve this goal? Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? 3. (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. Which of the following statements should the preceptor make? Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. 4. b. 3. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. Question: A charge nurse is making client care assignments. 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. Which clients could be assigned to an LPN? But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. Which of the following statements should the nurse make? 1., 2., 3., & 4. 3. 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. 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. Which preoperative prescription should the nurse question? A nurse is caring for a client who states, "I have got to get out of this hospital! A nurse instructs a female client about collecting a midstream urine sample. When determining if the client is eating a well-balanced diet 4. Which of the following responses should the nurse provide? 4. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). 5. c. Behaving defensively 2. A charge nurse is making client care assignments. A nurse is caring for a client who is postoperative following abdominal surgery. Select all that apply Select all that apply b. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. a. *HURST REVIEW Qbank/Customize Quiz - Manageme, *HURST REVIEW Qbank/Customize Quiz - Adult He, *HURST REVIEW Qbank/Customize Quiz - Basic Ca, *HURST REVIEW Qbank/Customize Quiz - Fundamen, ***HURST REVIEW NCLEX-RN Readiness Exam 1***, The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Edge Reading, Writing and Language: Level C, David W. Moore, Deborah Short, Michael W. Smith. Tenderness over the symphysis pubis The nurse has another priority. Which nurse should be assigned to care for this client? When assigning nurses to patients, the charge nurse must consider the acuity of the patient's condition, the skills of the nurse, and the availability of other staff members. Which of the following info should the nurse include? Which of the following actions should the nurse take? This stage involves constructive efforts on the part of the group members 4. c. Depression What proposal would the nurse determine to best meet the needs of families and clients in long term care? Select all that apply The nurse is using which level of communication at this time? A nurse is providing care to a client who is on strict bed rest following surgery. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. c. Environment Which of the following approaches should the nurse use when using confrontation? Use the tablet's packaging to pick it up from the counter d. Talk with the client's partner, b. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Incorrect: This response overlooks a potentially severe problem. The charge nurse must triage and assign clients to appropriate staff. What interventions can the nurse delegate to the LPN/VN? This is the most stable of the four clients which places this client last to be seen. 3. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. 3. In which harmonic number n is the string vibrating? A charge nurse is making client care assignments. The client can indicate desire for Do Not Resuscitate (DNR). c. Foot You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. a. The unit is short one staff member and will receive a nurse from the medical surgical unit. Show client who has conjunctivitis how to clean the eyes. 2. a. I'll urinate a little then stop 6. A client who is disoriented and awaiting transfer to a long-term care facility. Feedback d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. A nurse is preparing a sterile field. 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. c. Open the right flap with the left hand Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. a. I'll apply ankle to my ankle today and tomorrow The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Remind the client that a signed informed consent form is a legally binding document Ambulating a client who is 2 days post vaginal hysterectomy The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. c. Why are you crying? Encourage client to express grief related to loss of independence. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. However, it remains true pain for this client and the client would need intervention to help manage this pain. He charge nurse is making client care assignments for the evening shift. b. Wash the area of the puncture thoroughly with soap and water One important aspect is encouraging the flow of ideas between management and staff members. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. b. Correct: The client who has a cast and requires pain medication is a stable and predictable client. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Draining the colostomy bag on a client with diarrhea. 2. Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. a. Report of feeling pressure The nurse should perform which of the following activities in this space? b. 2. d. 216, 22. The nurse cannot allow the UAP to perform advanced tasks. They have found my address and are coming for my family!" Perform the Heimlich maneuver Obtain a urine specimen from a client with an indwelling Foley catheter. The facility has insurance that will cover malpractice litigation A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Besides yourself, there are the following staff: Your unit has 12 beds. Offer to take one of the clients. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. a. Discarding the first urine voided by the client starting a 24 hour urine test. The client asks the nurse, "Why do I need that? The nursing supervisor may be able to assist with client care until another nurse can come in to work. Give magnesium citrate 296 mL at 3 PM today. d. Identifying the client by name when making a referral for home health services, 30. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. 5. The nurse should do this when repositioning is needed. a. Bathe a client who had an amputation 2 days ago Which response by the LPN is appropriate in response to the inappropriate delegation? This action is a defensive intervention, and does not address the quarrelsome behavior. Right forearm 3. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. 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. A two-hour limit on visits discourages quality time. A family member requests that the nurse apply restraints. A school-aged child with a fractured femur who is in balanced suspension traction. 3. 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. Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. Only a plain enema or soap enema can be given by the UAP. 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). Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. 3. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. c. They tend to use more verbal communication Airborne Lisinopril 20.0 mg PO daily There are a total of 10 adult clients. The client is apparently stable and does not require any advanced assessment skills or specialized care. Narrative interaction Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. 7. This client could be transferred with traction still maintained. 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. The best practice committee works to improve clinical practice based on current research. Handoff and Nursing Report Sheet. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Incorrect: The RN is responsible for teaching. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. The last client would be the one needing dietary education. Which of the following actions should the nurse take prior to administering the tube feeding? The third client would be the one needing a dressing change. 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. Discuss the issue with the leader of the "best practices" committee. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? 1. Did you recognize ureterolithiasis as "kidney stones"? 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. Ask client if they are eating small, frequent meals. a. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. c. Palpating for pedal edema Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. A nurse asks a client to share personal stories. When a family member asks how respite care can help, which of the following responses should the nurse provide? This is not a situation that requires the LPN to notify the primary healthcare provider. A nurse is planning to discharge a client who has quadriplegia to his home. Comatose client with end stage chronic obstructive pulmonary disease. Witness the client's signature Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. 4. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Based on these findings, to which of the following providers should the nurse request a referral for the client? Respite care allows the primary caregiver time away from day-to-day care responsibilities b. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 2. The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. c. Hand-off technique a. Feed a client that had a stroke 3 months ago. Aplastic anemia is a rare but serious condition. Which actions should be instituted by each unit's charge nurse? & 5. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. To remove gastric acid that might cause dyspepsia The nurse caring for the client at the time of death requests organ donation The nurse prefers to check all vital signs on all clients. b. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. This would be out of the UAP's scope of practice. d. Remove and reinsert the NG tube, a. What is the appropriate assignment? The charge nurse's best response is to first obtain the needed information to make the best decision. Increased insulin production This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. But the client does need to be assessed prior to the client with Crohn's disease who is improving. 1. c. imaginary UAPs can assist with elimination and are taught how to measure output. 1. 6. Photo comes from the Greek word for light. 1. 5. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. A nurse who is 10 weeks pregnant. e. Suctioning a client's new tracheostomy tube, 93. Sudden attacks of sleep a. 4. A nurse is providing discharge teaching for a client who requires home oxygen therapy. 2. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. 5. The assignment process requires constant evaluation and reevaluation of information and priorities. Explore the client's feelings 2. 2. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. 3. What options would be appropriate for the nurse to take? Currently, your census is 11, with one empty bed. c. Discard the tablet and obtain another dose of medication 4. a. I will wear gloves when removing food from the freezer 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). 1. a. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following responses should the nurse make? 2. 3. 1. d. Reduced blood viscosity, a. Auscultating heart sounds Electric cords behind the furnitrure 1 Which of the following actions is an example of a violation of confidentiality? c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). c. Decreased sodium excretion This is an appropriate and safe action for the unlicensed nursing assistant to do. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Female client stating she has been raped. Speak to the UAP first and then decide if a between meal supplement is needed. A nurse is completing discharge teaching with a client. 4. The client receives home health care and spends most of his day in a reclining chair. c. Raised toilet seats e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. e. Feed a client who had a stroke 3 months ago, 31. They are more direct when discussing issues Elevating the head of the bed 30- 40 for the client post thoracotomy Accept the client's behavior as confrontational. a.) 3. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. This client is not the nurse's first priority. A charge nurse is making client care assignments. Ask the client to perform a return demonstration of insulin injection Stand directly in front of the client Invite staff to contribute ideas on scheduling changes. Also, making a surgical bed for the client returning from surgery is a basic procedure. d. Mask, 83. 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. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. A nurse is engaging in relationship counseling with a male client. 4. 1. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. 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. c. Changing a dressing, 78. 4. 1., 2., 3., & 4. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Limit the client's fluid intake in the evening