Incorrect: The nurse retains the responsibility for the delegated task. 4. (Select all that apply) 4. A client requesting assistance packing his belongings for discharge later today.. 1. a. c. Do not eat or drink anything the morning of the test Confrontation should occur in the presence of a charge nurse or supervisor. Remember, pick the killer answer first! b. 2. Right forearm So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. c. Distended bladder Sudden attacks of sleep This service focuses on teaching the primary caregiver to meet the client's needs IV of D5 NS at 75 mL/hour with a 20 gauge catheter. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Review a low-sodium diet for a client who has hypertension. 4. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Tenderness over the symphysis pubis 4. 5. 2. a. The client is considered unstable until assessed by the nurse. 5. The nurse also needs to be aware of the color and amount of urine voided. b. I'll do exercises that strengthen my abdominal muscles When determining if the client is eating a well-balanced diet Fundamentals Practice Flashcards | Quizlet Following a large hurricane, multiple clients arrive at the emergency room for treatment. Use the tablet's packaging to pick it up from the counter The charge nurse is making client assignments for a neuro-medical floor. Incorrect: This client does not have a predictable outcome. c. Nonfat milk Besides yourself, there are the following staff: Your unit has 12 beds. 9. Decide which choice fits best in the blank. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. It can result in muscle spasm and tissue damage. Correct. 1. Which of the following tasks should the charge nurse reassign to a licensed nurse? 2. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. What is the most appropriate action by the charge nurse? A school-aged child with a fractured femur who is in balanced suspension traction. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. 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. A nurse is caring for a client who is about to have a colonoscopy. Make referrals to community services. A nurse just back from maternity leave. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. What options would be appropriate for the nurse to take? This is an elderly client who is a new admit. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. d. The nurse has already considered alternatives to restraints, a. Administering 3 g/hr IV of morphine would be extremely dangerous. c. Confrontation -Review a low-sodium diet for a client who has HTN A nurse who is on hormone replacement therapy. 3. "Please explain what you mean by the word 'nervous'.". The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. c. Contact Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. 3. Describe the types of machining operations that can be performed on a lathe. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Twist at the waist when she moves an object to one side A nurse is caring for a client who has emphysema and has difficulty with mobility. Two nurses lifting the client under the shoulders The client is apparently stable and does not require any advanced assessment skills or specialized care. This action is a defensive intervention, and does not address the quarrelsome behavior. 6. 1. 3. a. What client should the nurse assess first? M2.4 Making Client Care Assignments - GECC.pdf - Course Hero Which of the following actions should the nurse include in the plan? Drag and Drop the items from one box to the other. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. Incorrect: This group of clients needs specialized care. Which of the following types of torts has the nurse committed? A nurse wants to find out a better way to perform oral care on unresponsive clients. 3. They are more direct when discussing issues Which client can be assigned to the LPN? d. Providing information, a. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. c. Physical therapist b. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. c. Discard the tablet and obtain another dose of medication Which clients should be assigned to the CNA? a. 3. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. A client with diabetes admitted for debridement of a foot ulcer. Give magnesium citrate 296 mL at 3 PM today. 6. Which of the following info should the nurse include? Assist a client to ambulate using a gait belt 3. b. I will bear the weight of my body on my hands It is quicker to administer medications intravenously in the hospital Which of the following actions should the nurse take? 1., 2., 3., & 4. Select all that apply. c. Tie linen bags securely at the top The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 2. Gather supplies to prepare room for isolation. To remove gastric acid that might cause dyspepsia The nurse is planning care for a client admitted with Alzheimer's Disease. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. Richied5864 Richied5864 . Lisinopril 20.0 mg PO daily 1., 2., 3., & 4. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. Measuring vital signs Ambulating a client who is 2 days post vaginal hysterectomy Offer to take one of the clients. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". All these clients have a GI problem. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Check environment for potential safety hazards. Stand directly in front of the client Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. Simply accept the assignment since overtime is mandatory. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. 2. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Which of the following actions should the nurse include in the plan? Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? the nurse responds, "don't worry, no one will harm your family." a. Auscultate breath should at least ever 2 hr Which nurse should be assigned to care for this client? Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Request a prescription for a medication to ease the client's anxiety (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 Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? Who should the nurse see first? 2. a. 2., 3. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. d. Discussing intake and output c. When asking the client how he completes his ADLs A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. Correct. A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. 4. 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. d. 216, 22. 4. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. d. Proceed with the preparation of the patient's surgical procedure, 15. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. 3. a. 1. Temporary urinary retention (common for clients to develop after removal), 90. 4. Elderly client admitted 30 minutes ago with reports of constipation for four days. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Well, do you see the q.d.? Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Incorrect: This again is assessment which is the role of the RN only. Send a day's worth of medications with the client to the receiving facility. d. Perception 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. Elderly clients have special fluid and electrolyte issues after a fall. 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. Invite staff to contribute ideas on scheduling changes. Have another nurse guard the medication preparations until the nurse returns a. Elderly client who fell and fractured the left femoral neck. 1. Which of the following communication techniques should the nurse use during this phase? An adult (18 years or older) can create an advanced directive. 2. c. Review another client's similar surgical experience a. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Incorrect: Atrial fibrillation places the client at risk for blood clots. Which of the following actions should the nurse take prior to administering the tube feeding? c. Why are you crying? Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. 2. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Assign a nursing assistant to help the client with self-care activities. b. Read all the current literature related to oral care on unresponsive clients. b. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Perform the Heimlich maneuver A two-hour limit on visits discourages quality time. 3. 5. Select all that apply. Which of the following responses should the nurse make? A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. Correct: This group of clients is primarily med surgical. 4. Speak to the UAP to determine what happened with the feeding. Which of the following findings indicates that the client is meeting this goal? 1. An experienced person who can research "best practice" regarding the issue is needed. c. Explain the risks and benefits of the procedure c. Notify the nurse manager c. imaginary Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Provides day to day direction and supervision to assigneddirect patient care staff . c. I will complete the smoking cessation program I started 2. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? Talk to each nurse about concerns related to assigned clients. A client diagnosed with rheumatoid arthritis needing discharge teaching. A high concentration of carbon monoxide can cause death This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. 4. 1. 1. The nurse cannot allow the UAP to perform advanced tasks. A client with COPD complaining of shortness of breath on exertion. 1. There is a trailing zero after the prescribed dose. Reporting laboratory findings to a member of the client's family Solved 4. A charge nurse is making client care assignments. | Chegg.com b. c. Rephrase statements the client does not hear Hanging a new bag of total parenteral nutrition (TPN). Select all that apply PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Report of feeling pressure 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. 3. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. 1. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. The best practice committee works to improve clinical practice based on current research. 3. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Feedback 1. 3. 2. The key word in the stem is first. Reach around the pack and open the top flap away from the body The nurse has received the change-of-shift report. Injuries from a motor-vehicle accident can be life threatening. What is the appropriate assignment? Correct: An LPN/LVN's scope of practice includes tasks such as wound care. c. Changing a dressing (Select all that apply.) The client states, "I am so nervous about what the doctor might find during the test." Nothing by mouth (NPO). 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. e. Suctioning a client's new tracheostomy tube, 93. 4. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Suggest splitting the shift with another nurse. Which of the following tasks should the nurse delegate to assistive personnel (AP)? c. To determine the client's electrolyte balance The charge nurse's best response is to first obtain the needed information to make the best decision. 2. a. 4. 4. Select all that apply. This protein is released by cells in the stomach. NUR 112 Practice Assessment Flashcards | Quizlet Provides safe, effective delivery of patient care in . Measure urine output when client voids. This referral would be appropriate. A nurse is caring for a client who is postoperative following an appendectomy. 4. Review a low-sodium diet for a client with hypertension. Answer the following question to test your understanding of the preceding section: Which task should the nurse take responsibility for completing? Teaching insulin self administration to a diabetic client. We do not know the extent of her injuries based on what the option tells us. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. 5. 2. 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. A nurse is caring for a client who is postoperative following abdominal surgery. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. a charge nurse is making client care assignments for the day. The nurse should call for immediate help so that a safe care environment is maintained for all clients. Cystogram reporting burning on urination. Which of the following actions is an example of a violation of confidentiality? This assumption is not appropriate, and the feelings and concerns of the client should be addressed.