a. Documentation is a communication tool for the interprofessional health care team. This documentation should go to your manager. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. A nurse asks a client to share personal stories. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Perform the Heimlich maneuver a. b. b. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). 1. Which of the following actions indicates that the AP understands the principles of infection control? A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. c. Explore the client's feelings about dietary modifications Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. c. Changing a dressing, 78. Decreased or suppressed respiration are priority. c. Notifying the provider of physical exam findings Limit the client's fluid intake in the evening Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 3. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. Select all that apply Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 1., 2., & 5. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. b. 3. Respite care allows the primary caregiver time away from day-to-day care responsibilities The nurse could definitely be part of the committee. A nurse is filling out an incident report after finding a client lying on the floor. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. The client states, "I am so nervous about what the doctor might find during the test." a. b. 1. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 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 (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. 3. Select all that apply. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 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. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. (Select all that apply.). Comatose client with end stage chronic obstructive pulmonary disease. d. Droplet, d. Bend at the knees when picking up an object, 98. Remove all metal necklaces A nurse is implementing direct nursing care for a group of clients in an acute care facility. a. Battery b. Dons gloves to empty a urinary drainage device The nurse does not know the skills of the new UAP. d. Perception d. Message, 67. b. Summarization b. I'll rewrap my ankle starting from the knee down 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. 1, 3 & 5. A nurse just back from maternity leave. This client needs ongoing monitoring which is within the scope of practice for the LPN. b. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. This should not be delegated to the LPN/LVN. What is the appropriate assignment? This stage involves constructive efforts on the part of the group members A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). 1. The below statement corresponds to a numbered sentence in the passage. Which clients could be assigned to an LPN? 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. A nurse is planning care for a female client who has an indwelling urinary catheter. 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. 2. The client reports constipation for 4 days which may be an indication of worse problems. Which clients would be appropriate assignments for the LPN/LVN? 4. Incorrect: This client is exhibiting early signs of increased intracranial pressure. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. c. Hold an object away from her body as she lifts it 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. 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. 3. a. 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. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. 3. Explain oral hygiene to a client receiving chemotherapy 4. Also, making a surgical bed for the client returning from surgery is a basic procedure. b. Massage any bony prominences to promote circulation Which of the following statements should the nurse make? Explain administration is demanding a decreased overtime. 2. 5. The expected standard of care was strict bed rest), 96. Have another nurse guard the medication preparations until the nurse returns a. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. 5. 2. Remind the client to avoid tight fitting clothes. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Thus, the tasks involve successful management of the charge nurse's responsibilities. c. I should purchase a carbon monoxide detector for my home (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 4. A nurse is caring for a client who is postoperative. There are a total of 10 adult clients. Include any relevant statements the client made about the ulcer Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. Elderly client who fell and fractured the left femoral neck. 3. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. A nurse receives a client care assignment from the charge nurse that he believes is unfair. 4. Use adult diapers to prevent frequent clothing changes Place the client in a lateral position Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. c. Holds the soiled linen against her body while carrying it to the linen bag 8. c. Include intact skin at the wound edges in the culture Select all that apply. Client who has multiple injuries from a motor vehicle accident. Lisinopril 20.0 mg PO daily Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. Reporting laboratory findings to a member of the client's family b. I should call my doctor if I find it harder to concentrate Once the client is stable, the UAP could perform this task. 1. Which of the following statements should the nurse make? Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. Transfer essential medical record to the receiving facility. Which of the following actions should the nurse take to assist the client with feeding? Notify the board of nursing (BON) that the float nurse is an alcoholic. 3. Give magnesium citrate 296 mL at 3 PM today. The nurse is caring for four clients. Showing disapproval A client with diabetes admitted for debridement of a foot ulcer. b. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. c. Paraphrasing Which of the following actions should the nurse take? 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. Request a prescription for a medication to ease the client's anxiety This service began with the client's admission to the hospital 3. 4. The nurse voices his concern to the charge nurse. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? c. Washes and rinses her hands for 10 seconds ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. a. Which of the following actions should the nurse take first? A nurse is caring for a client who is immobile. Complete blockage of the large intestine. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Reach around the pack and open the top flap away from the body, 53. a. Show client who has conjunctivitis how to clean the eyes. A nurse is teaching a client who has a history of falls about home safety. Only a plain enema or soap enema can be given by the UAP. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. 4. 3. The nurse is reviewing some clients' prescriptions. 3. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. A nurse caring for a client is using active listening skills. 3. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. The LPN/LVN can reinforce teaching. Delegate 2 nurses to work with the client. 3. d. Explain oral hygiene to a client receiving chemo 2. C-section planning discharge, postpartum infection, mastectomy. If you give the magnesium citrate, which is a laxative, what will happen? 4. Client with ureterolithiasis who requires frequent PRN pain medication. d. Routine acquisition of a urine specimen 5. 3. Nothing life threatening, but an assessment needs to be made regarding the ulcer. a. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Which of the following responses should the nurse make? 1., 4., & 5. Correct: The client has the right to be involved in the decision making of their care. Encourage clients and families to develop mutually appropriate visitation times. 1. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 5. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Feedback Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Review a low-sodium diet for a client who has hypertension. Encourage client to express grief related to loss of independence. c. Face shield This includes medication enemas. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Because the charge nurse observes and weighs . Select all that apply Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? 4. 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. 5. b. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Simply accept the assignment since overtime is mandatory. 1. 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. 4. a. Clarification e. Feed a client who had a stroke 3 months ago, 32. c. Washes and rinses her hands for 10 seconds, 11. Photo comes from the Greek word for light. Which of the following tasks should the nurse delegate to assistive personnel (AP)? b. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Right forearm The surgeon initially prescribes a clear liquid diet. Gather supplies to prepare room for isolation. 4. 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. b. I will come back later and we can talk d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. c. Raised toilet seats Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Besides, a charge nurse is a leader on the floor and should possess . a. d. Transporting a cerebrospinal fluid specimen to the lab d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. This service began with the client's admission to the hospital, 18. A nurse instructs a female client about collecting a midstream urine sample. a. a. 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. (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 Provide an adaptive feeding device for the client, 50.