2. 2. Focus on the client's present circumstances instead of his personal stories 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. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. b. Assess the client A nurse is assessing a client at a follow-up clinic for acute low back pain. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? d. Remove and reinsert the NG tube, a. - Assisting a client to ambulate using a gait belt. The body needs vitamin B12 to make red blood cells. b. Nurses dependent on drugs or alcohol can harm clients. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. a. a. Which of the following actions should the nurse take? A client with an above the knee amputation reporting phantom pain. 5. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. 3. A nurse wants to find out a better way to perform oral care on unresponsive clients. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Feedback 4. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. The healthcare team should recognize the client as the center of the team. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Denial Alert all off-duty personnel to stand by in case of call- in. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. a. Which of the following statements should the nurse identify as an indication that the client understands the instructions? Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Which of the following actions is the priority for the nurse to include in the client's plan of care? Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Monitor for GI upset 30 minutes after meals. 2. A nurse is teaching a client who has a history of falls about home safety. 3. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Tenderness over the symphysis pubis Which of the following actions should the nurse include in the plan? b. a. I will begin 48 hr before the client's discharge 1. 3. c. I'll wear low heeled shoes from now on A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. d. Message, 67. 4. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. 2. 3. 1. Discarding the first urine voided by the client starting a 24 hour urine test. b. c. Gender What action should the nurse take after mistakenly administering the wrong medication? 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). Charge Nurse II- CNII - jobs.freseniusmedicalcare.com If a sentence is already correct, write CCC. c. Raised toilet seats This client could be transferred with traction still maintained. 2. which client would be most appropriate to assign a licensed practical nurse (lpn)? Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Start MgSO4 at 3g/hr IV b. -Review a low-sodium diet for a client who has HTN Return any fresh linen not used for a client to the linen supply area Where on the body is each type of skin found? To confirm the placement of the NG tube A nurse is caring for a client who expresses anxiety about his impending surgery. 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. 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? Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Because the charge nurse observes and weighs . A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. 4. d. Explain oral hygiene to a client receiving chemo b. I'm so sorry to hear about this Increased insulin production The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Solved A charge nurse is making client care assignments. | Chegg.com This is an appropriate and safe action for the unlicensed nursing assistant to do. Client diagnosed with Guillain-Barre' who is receiving ventilator support. is a new graduate in orientation. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. _____The house that we lived in for nine years has been sold. The infusion rate has stopped but the tubing is not kinked 3. c. Take the client to the bathroom every 2 hr Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. The abdominal pain is worsening. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. An LPN/VN has been floated to the emergency room following a chemical plant explosion. Correct. a. d. Complete an incident report, 70. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. b. Emptying a urinary drainage bag for a client who has pneumonia assignmentcafe.com - A charge nurse is making assignments for nursing c. Blood-tinged urine Provides safe, effective delivery of patient care in . What options would be appropriate for the nurse to take? b. 3. Write N next to the nonessential clauses and E next to the essential clauses. However, there are some basic points which are standard among all facilities. Place in priority order. Which clients should be assigned to the CNA? Documentation of what occurred, and the client's assessment is required in the nurse's notes. A goal for this client is to use proper body mechanics at all times. Remember, pick the killer answer first! a. 4. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. b. Richied5864 Richied5864 . 4. Decreased or suppressed respiration are priority. 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. Female client stating she has been raped. d. Let's wait until tonight to see if he continues his behavior, 63. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? A nurse is caring for a client who is postoperative following abdominal surgery. Therefore, this would not be the most appropriate nurse to assign to this client. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. Checking capillary refill beneath the client's fingernail It is within the LPNs scope of practice to administer antibiotics. The nurse has another priority. b. Select all that apply a. Bathe a client who had an amputation 2 days ago Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. (SATA) -Bathing a client who had an amputation 2 days ago. c. Respite care helps relieve pain and promote comfort A client with a fractured right humerus who reports the cast is too tight. Incorrect: This again is assessment which is the role of the RN only. 6. A charge nurse is making client care assignments. a. Auscultate breath should at least ever 2 hr Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Incorrect: The charge nurse does not have to assess every client. This would be out of the UAP's scope of practice. d. Talk with the client's partner, b. Client reporting epigastric pain and nausea after eating. 1. c. Industry vs inferiority Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? 1. 3. A client with epilepsy reporting an odd smell in the room. Twist at the waist when she moves an object to one side Include any relevant statements the client made about the ulcer, 64. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. It contains a blank and is followed by four answer choices. What is the best care assignment for this client? Which of the following activities should the nurse perform in this zone? It is not a routine task. 4. d. Reduced blood viscosity, a. Auscultating heart sounds Correct: Communication is important in delegation, as is follow-up. Which of the following sites should the nurse plan to use to obtain the blood specimen? 5. c. Decreased sodium excretion Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Understanding the charge nurse's role in staffing The surgeon initially prescribes a clear liquid diet. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Ask for any staff objections to rearranging work hours. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. Channel Compartment syndrome could be developing which can impede circulation and cause nerve damage. c. I should purchase a carbon monoxide detector for my home Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? b. Wash the tablet off with alcohol and place it in a clean medicine cup 2. 4. 1. d. I decline this opportunity at this time, b. A nurse is administering a cold therapy application to a client. In what order should the emergency department triage nurse send these clients to a room for treatment? 1. An adolescent client post appendectomy reporting pain. 3. 4. 3. It's unfortunate that I have to be in the hospital for this treatment a. Hypotension 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. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? The spouse can rescind the Advance Directive if the client becomes unresponsive. 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. 4. Pernicious Anemia Society The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. d. Social conversation, a. Allow the UAP to work without supervision. a. Broth Which of the following findings associated with urinary retention should the nurse expect? The nurse does not know the skills of the new UAP. Document current functional status assessment Sudden attacks of sleep c. The client's culture The client with cystitis is stable and has a predictable outcome. Sudden attacks of sleep Which of the following infection-control precautions should the nurse use caring for this client? Monitor client for pain while assisting with ambulation. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Electric cords behind the furnitrure Select all that apply. A two-hour limit on visits discourages quality time. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 3. b. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. The nurse should do this when repositioning is needed. The nurse also needs to be aware of the color and amount of urine voided. d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. The client is considered unstable until assessed by the nurse. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. A charge nurse is making client care assignments. When staff do not feel vested in any new process, there is a sense of underappreciation. Providing a passive response 5. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. A charge nurse is planning client activities for the day. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. a. I will wear gloves when removing food from the freezer The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. d. Place the tablet directly into a medication cup, 36. 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. Include any relevant statements the client made about the ulcer The surgeon initially prescribes a clear liquid diet. When the licensed person cannot determine this, the task should not be delegated. b. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Places the soiled linen in the floor before bagging it Select all that apply d. Routine acquisition of a urine specimen 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. Place the client in low Fowler's position Reach around the pack and open the top flap away from the body, 53. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? Which response by the LPN is appropriate in response to the inappropriate delegation? Printable Nursing Brain SheetPrintable Nursing - soyu.caritaselda.es Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. The nurse should call for immediate help so that a safe care environment is maintained for all clients. On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. Briefly assess every client. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. A nurse caring for a client is using active listening skills. d. I have a set of my brothers' crutches in the basement I can also use, a. b. Which of the following actions should the nurse take to assist the client with feeding? The provider must renew a restraint prescription every 8 hr. They are likely to wait for others to initiate conversation The LPN/LVN can reinforce teaching. Oral surgeon 2. Besides yourself, there are the following staff: Your unit has 12 beds. 2. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. 2. The charge nurse must triage and assign clients to appropriate staff. Removing the abdominal dressing It also helps the client deal with issues that are important to him), 19. 2. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. 1. b. 4. c. Inform the surgical team to cancel the client's surgery Turn on local news for up-to-date information on the train derailment. b. I'll rewrap my ankle starting from the knee down The client can indicate desire for Do Not Resuscitate (DNR). Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Furosemide 40 mg PO q.d. Incorrect: This group of clients needs specialized care. 1. b. Offer to take one of the clients. Incorrect: Medications are not transferred with the client to a new facility. Explain to the RN that all the nurses have the same number of clients. b. I will come back later and we can talk Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Which of the following actions should the nurse take? b. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. This is not a situation that requires the LPN to notify the primary healthcare provider. a. Which of the following responses should the nurse make? Stand directly in front of the client a. _________________ (magnanimous), a. generous Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. 5. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain The nurse on a large surgical unit needs to evaluate several clients returning from procedures. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. The LPN can monitor the wound and provide care to the PEG insertion site. A nurse is filling out an incident report after finding a client lying on the floor. 3. 3. 2. A charge nurse on an acute care unit is planning care for a client Which clients should be assigned to the CNA? It's just not the right time for me to do this 1. Use the tablet's packaging to pick it up from the counter 4. 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. 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. 1. Encourage clients and families to develop mutually appropriate visitation times. Yes! 3. "The client is weak on the right side, so please assist the client with dressing . b. A nurse is caring for a client who is postoperative. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 2. 1. Which of the following tasks should the charge nurse reassign to a licensed nurse? Which group of clients should she assign to the medical surgical nurse? 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. 2. Delegate 2 nurses to work with the client. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. A lack of rapid eye movement (REM) sleep These individuals are selected by the charge nurse, and do not have to be nurses. Nothing by mouth (NPO). Well, do you see the q.d.? a. I'll apply ankle to my ankle today and tomorrow This client can wait until the others are treated. Feed the client after warming the food. A nurse enters an older adult client's room to insert a saline lock. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Phone report to the receiving nurse. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. 3. a. Which of the following instructions should the nurse give to the client prior to the procedure? Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Which task should the nurse take responsibility for completing? The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Incorrect: This response overlooks a potentially severe problem. The client's self-report of pain severity This service began with the client's admission to the hospital, 18. Select all that apply 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. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? 1. The charge nurse needs additional information to make a decision.
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