A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. 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. What is the major histological difference between thick and thin skin? The facility has insurance that will cover malpractice litigation Which of the following statements should the nurse identify as an indication that the client needs further instruction? The client receives home health care and spends most of his day in a reclining chair. 1. Provides day to day direction and supervision to assigned direct patient care staff. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following tasks should the charge nurse reassign to a licensed nurse? 3. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. The LPN/LVN can reinforce teaching. The abdominal pain is worsening. Dexlansoprazole 30 mg PO daily. b. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. The below statement corresponds to a numbered sentence in the passage. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Incorrect. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. Correct: The client may be experiencing a myocardial infarction and requires further assessment. and 16 g of fat. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). The nurse is caring for four clients. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Drag and Drop the items from one box to the other. So, now you must decide which of these high priority clients should be seen in what order. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 3. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 1. the nurse responds: "It must be very frustrating to encounter this kind of attitude." The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 1. A nurse is working with an assistive personnel (AP) to 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. Which of the following findings indicates that the client is meeting this goal? a. Bathe a client who had an amputation 2 days ago Which action should the nurse interrupt the UAP from performing? Which of the following actions should the nurse include in the plan? A nurse asks a client to share personal stories. c. Gender To confirm the placement of the NG tube c. 214 So, the UAP can assist a client to brush and floss teeth. 3. d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. Refuse the delegated intervention. 4. Charge nurses have integral roles in healthcare organizations. Which of the following actions should the nurse take? Initiative vs guilt The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. A client requesting assistance packing his belongings for discharge later today.. Confrontation should occur in the presence of a charge nurse or supervisor. Client who has multiple injuries from a motor vehicle accident. The RN with 10 years' experience pulled from the ER. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). It also helps the client deal with issues that are important to him), 19. Disconnect client's nasogastric (NG) tube suction to allow ambulation. a. b. Wash the area of the puncture thoroughly with soap and water Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? A nurse is teaching a client who has a history of falls about home safety. 1. What is the most appropriate action by the charge nurse? c. Consensus evolves in this stage For which of the following tasks should the nurse wear protective eye equipment. One nurse lifting as the client pushes with his feet A nurse is caring for a client who is postoperative following an appendectomy. a. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. There is a possibility that a hypothermia blanket may be prescribed. 4. 1. Teach caregivers memory enhancement aids. What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? A nurse is teaching a client about carbon monoxide poisoning. Select all that apply b. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. This is likely cholelithiasis, which will need to be checked out. Charge Nurse II- CNII - jobs.freseniusmedicalcare.com 3. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter NURSING ASSIGNMENT- delegation in the workplace | Studymonk Select all that apply a. Gathering needed equipment and supplies is within the scope of duties for the UAP. M4 Client Care Assignment.pdf - Making Client Care 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. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. Correct. The nurse does not know the skills of the new UAP. Feed a client that had a stroke 3 months ago. d. Remove and reinsert the NG tube, a. 1. A charge nurse is making client care assignments. The surgeon initially prescribes a clear liquid diet. 3. Female client stating she has been raped. 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. Which of the following client statements indicates an understanding of the procedure? The supervisor can only send one LPN/LVN to the floor. d. They disclose more personal information, a. Once the client is stable, the UAP could perform this task. a. I'll provide more stimulation in his environment a. 1. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. Provide positive feedback to the UAP. Complete blockage of the large intestine. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. What task would be best to assign to the LPN/LVN? Discuss the assignment with another LPN. Administering IV pain medication to a two day post op client. Irrigate a client's ear canal. Fruity breath. Discarding the first urine voided by the client starting a 24 hour urine test. Encourage clients and families to develop mutually appropriate visitation times. Offer to take one of the clients. 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. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Explain oral hygiene to a client receiving chemotherapy Select all that apply Decide which choice fits best in the blank. Document current functional status assessment d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. b. b. 4. 3. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. Start MgSO4 at 3g/hr IV Which of the following info should the nurse include? What is the appropriate assignment? The infusion rate has stopped but the tubing is not kinked b. 7. Monitor for behavioral changes. Drag and Drop the items from one box to the other. This service focuses on teaching the primary caregiver to meet the client's needs This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? c. Contact What was the rationale for this plan? Feed the client after warming the food. 2. a. 1. Correct: Traction should never be relieved without a primary healthcare provider's prescription. d. Remove tea and coffee from meal trays, b. Richied5864 Richied5864 . However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. 2. Thoracentesis reporting shortness of breath. Invite staff to contribute ideas on scheduling changes. Bargaining Which of the following sites should the nurse plan to use to obtain the blood specimen? Which of the following items should the nurse include on the lunch tray? A two-hour limit on visits discourages quality time. c. I will place an area rug at the entry of my bathroom 2. (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 d. Discussing intake and output Assist a client to ambulate using a gait belt. Select all that apply b. Verbalize understanding of how the client feels a. 2. 2. A nurse is providing discharge teaching for a client who requires home oxygen therapy. 1., 2., 4., & 5. Which of the following interventions should the nurse include? This would be out of the UAP's scope of practice. 1. The third client that should be sent back for treatment is the female client stating she has been raped. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. 6. Report the incident to the charge nurse 4. Which of the following actions is an example of a violation of confidentiality? Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. Performing passive range of motion (ROM) on the client with right sided paralysis. c. Foot Which of the following communication techniques should the nurse use during this phase? A family member requests that the nurse apply restraints. What was the hint? 2. Ask for any staff objections to rearranging work hours. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Assessing this client and titrating the diltiazem requires the skills of an RN. c. Helping the client into the shower For which of the following actions should the nurse intervene? Have a pen and paper handy Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. Which of the following types of torts has the nurse committed? a. A client with fibromyalgia reporting generalized pain of 7 out of 10. A nurse is caring for a client who is postoperative. 5. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Which of the following actions indicates that the AP understands the principles of infection control? 4. This client will also need a lot of education regarding anti-rejection medications. d. principal. Client eating a simple-carb snack due to weakness. b. NUR 112 Practice Assessment Flashcards | Quizlet 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. The charge nurse needs additional information to make a decision. Which of the following statements should the nurse identify as an indication the client needs further teaching? b. b. I will call the doctor and get the prescription It can result in muscle spasm and tissue damage. A Charge Nurse Role: The Ultimate Guide. b. Solved 77. The nurse in a long-term care facility is making - Chegg 2. Besides, a charge nurse is a leader on the floor and should possess . "The client is weak on the right side, so please assist the client with dressing . Provide an adaptive feeding device for the client, 50. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide UAP with the best directions about an assignment? c. Depression 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. 6. 2. c. Palpating for pedal edema This protein is released by cells in the stomach. This referral would be appropriate. Solved 4. A charge nurse is making client care assignments. | Chegg.com c. Holds the soiled linen against her body while carrying it to the linen bag Inform the client of the need to avoid irritants such as carbonated beverages. b. d. When asking if the client took his medications this morning, 82. This would be out of the UAP's scope of practice. A nurse is caring for a client who is scheduled for an elective surgical procedure. Teaching insulin self administration to a diabetic client. c. Review another client's similar surgical experience 2. a. Clarifying 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. 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. Explain to the RN that all the nurses have the same number of clients. a. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. 4. The client asks about his medications and their effects. Allow the UAP to work without supervision. However, there are some basic points which are standard among all facilities. Which clients should be assigned to the CNA? Provide a between meal supplement to the client. A nurse instructs a female client about collecting a midstream urine sample. 4. Making client care assignments As the RN charge | Chegg.com When staff do not feel vested in any new process, there is a sense of underappreciation. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. c. Face shield Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. 4. A nurse is having difficulty caring for a client due to variables affecting the communication process. a. Semi-formed stools are great news! Notify clients that the disaster plan has been put into effect. Perform the Heimlich maneuver When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. 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). 1. Show client who has conjunctivitis how to clean the eyes. 2. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. These are appropriate tasks for an UAP to complete. Initiate oxygen and IV lines as needed. 4. 4. Based on this information,what should the nurse do? 2. Encourage the client to be more cooperative. Now, in Option #2, we see a dangerous prescription. 4. This includes medication enemas. Determine caregiver's stress level and coping strategies. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. Which of the following actions by the nurse is considered an indirect nursing care activity? A nurse is admitting a client who has a partial hearing loss. 3. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. b. Irrigate the wound with an antiseptic prior to obtaining the specimen b. This is not a situation that requires the LPN to notify the primary healthcare provider. Feedback d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. 4. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. There are a total of 10 adult clients. Hold the penis at a 30 to 45 degree angle when inserting the catheter The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Incorrect: This again is assessment which is the role of the RN only. a. 2. Focus on the client's present circumstances instead of his personal stories The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). The client should be assessed first to rule out respiratory difficulty and hemorrhage. Which of the following infection-control precautions should the nurse use caring for this client? Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. a. Elicit info from the client A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Feedback 2. 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. The charge nurse is planning assignments on a medical unit Which client Select all that apply 9. 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). 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. A client with atrial fibrillation currently on a diltiazem drip. Incorrect: The charge nurse does not have to assess every client. This client is stable and predictable. Teaching insulin self administration cannot be delegated to the LPN. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. The nurse should not be assigned to provide care if impairment is suspected. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. 4. Discuss the issue with the leader of the "best practices" committee. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam.