a charge nurse is making client care assignments a charge nurse is making client care assignments

Respite care allows the primary caregiver time away from day-to-day care responsibilities 2. 6. 3. 4. a. d. I decline this opportunity at this time, b. A nurse is preparing medication for a client when another client has an emergency. A nurse is teaching a client who has a history of falls about home safety. Which of the following actions should the nurse take first? 1. A nurse is preparing to move a client who is only partially able to assist up in a bed. Assist a client to ambulate using a gait belt a. Elicit info from the client 3. In option #4, we see that the leading zero is missing from the prescription. A client on a surgical unit frequently quarrels with the staff. b. b. Temporary urinary retention (common for clients to develop after removal), 90. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Besides, a charge nurse is a leader on the floor and should possess . 5. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 1. 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. b. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. Dexlansoprazole 30 mg PO daily. 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. 3. which client would be an appropriate care assignment for this lpn? Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Which of the following responses should the nurse make? c. Use intermittent eye contact A high concentration of carbon monoxide can cause death Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Select all that apply a. Which task should the nurse take responsibility for completing? b. I'll rewrap my ankle starting from the knee down Nurses dependent on drugs or alcohol can harm clients. 4. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. 1. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. A nurse asks a client how he is feeling. 212 Correct. 2. a. Removing the abdominal dressing The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. c. Tie linen bags securely at the top a. Serve milk products separately from meals Which of the following statements should the nurse identify as an indication the client needs further teaching? 1. a. I will begin 48 hr before the client's discharge A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 4. Client diagnosed with Guillain-Barre' who is receiving ventilator support. 2. The nurse caring for the client at the time of death requests organ donation Remind the client to avoid tight fitting clothes. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 4. Select all that apply. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. 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 surgeon initially prescribes a clear liquid diet. a. d. Respite care is a continuation of psychological support after a family member dies. 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. Hanging a new bag of total parenteral nutrition (TPN). This would be out of the UAP's scope of practice. 3. Allow families unlimited visitation around the clock to meet their schedules. d. I shouldn't advice you about what is ultimately a personal decision, b. Which of the following statements should the nurse identify as an indication that the client needs further instruction? (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 Select all that apply. Collecting I & O totals for unit clients at the end of shift. a. Reposition the client every 3 hr 1., 2., 3., & 4. a. b. d. Counting radial pulse, 100. 2. 2. 3. c. Malpractice c. Nonfat milk Teaching insulin self administration cannot be delegated to the LPN. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. a. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. The nurse prefers to check all vital signs on all clients. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. Draining the colostomy bag on a client with diarrhea. 1. Perform catheterization when you recognize the urge to void The nurse also needs to be aware of the color and amount of urine voided. the nurse should delegate collection of which of the following specimens to DismissTry Ask an Expert Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Harvard University University of Georgia Maryville University Providing a passive response Check environment for potential safety hazards. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Which of the following explanations should the nurse provide? Which of the following findings associated with urinary retention should the nurse expect? c. Hallucinations at the onset of sleep As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. 4. Electric cords behind the furnitrure The first vital sign check was performed by the nurse. Decreased or suppressed respiration are priority. The nurse considers various ideas submitted by team members. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Use the tablet's packaging to pick it up from the counter Feed the client after warming the food. 2. The cause of the fall may be cardiac, but the question does not indicate this. It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. Incorrect: The nurse cannot assign teaching to the UAP. . b. I will begin once the client's discharge order is written 4. Well, do you see the q.d.? and 16 g of fat. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. This service focuses on teaching the primary caregiver to meet the client's needs 2. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. There will likely be both physical and emotional injury that needs attention, which places this client third. c. Behaving defensively d. Transporting a cerebrospinal fluid specimen to the lab a. Shakes the soiled linen to remove any toilet paper remnants 4. c. Blood-tinged urine A nurse is caring for a client whose partner asks to speak with the nurse. 3. 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. d. Determine if the client uses hearing aids, b. The cleint's family asks the nurse for info about this type of care. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? Which of the following communication techniques should the nurse use during this phase? Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. Client with chronic emphysema experiencing mild shortness of breath. What client should the nurse assess first? Schedule visiting times in two-hour increments so clients are not overwhelmed. Discussing a client's surgical procedure with the nurse manager No! Which of the following client statements should indicate to the nurse the need for additional teaching? Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. c. Inform the surgical team to cancel the client's surgery (Select all that apply.). The client is reporting anxiety, discomfort, and a feeling of bloating. What is the best first action for the nurse to take in order to achieve this goal? This client will also need a lot of education regarding anti-rejection medications. A client who is disoriented and awaiting transfer to a long-term care facility. Which of the following physiological responses to prolonged immobility should the nurse expect? Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. A nurse is planning care for a female client who has an indwelling urinary catheter. b. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. A nurse is caring for a client who is immobile. Now, in Option #2, we see a dangerous prescription. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. A nurse asks a client to share personal stories. 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. During exacerbation, the client will have many diarrhea stools. b. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. Monitor for GI upset 30 minutes after meals. c. Request a tray without pork This would be out of the UAP's scope of practice. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). a charge nurse is making client care assignments for the day. 4. A nurse is preparing a sterile field. Change the subject when the client behaves defiantly Use double bagging to remove soiled linen from the client's room Wears a gown when entering the room of a client who requires contact precautions A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Which actions should be instituted by each unit's charge nurse? Which of the following responses should the nurse make? 5. The nurse should use close-ended questions when assessing which of the following factors? 5. The nurse received a client following surgery 8 hours ago. c. Contact A medical-surgical LPN has been sent to a short-staffed pediatric unit. The best practice committee utilizes current research in their recommendations. Compartment syndrome could be developing which can impede circulation and cause nerve damage. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. However, providing care for missing teeth would also be within the LPN scope of practice. Each state BON differs in that also some have treatment programs they administer themselves. Select all that apply Incorrect: Atrial fibrillation places the client at risk for blood clots. 2. 3. Which of the following statements should the preceptor make? Which of the following is the priority action by the nurse? Removing the client's dentures b. b. I'll use the cleansing wipes from the front to back A nurse is teaching a client about carbon monoxide poisoning. Stand directly in front of the client 6. Only a plain enema or soap enema can be given by the UAP. a. 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. Determine which personnel could be sent to the command center. Teaching insulin self administration to a diabetic client. In the following sentences, circle each incorrectly used lowercase letter. 4. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Photo comes from the Greek word for light. b. Summarization A charge nurse is making client care assignments. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. A nurse is planning to discharge a client who has quadriplegia to his home. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. 3. Incorrect: Medications are not transferred with the client to a new facility. It is within the LPNs scope of practice to administer antibiotics. Nothing life threatening, but an assessment needs to be made regarding the ulcer. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Refuse the assignment, being prepared for disciplinary action. This could cause a medical emergency. b. d. Social conversation, a. 3. The surgeon initially prescribes a clear liquid diet. 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. 1. c. Confrontation In what order should the nurse see the clients? Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. (Select all that apply.). a. I'll apply ankle to my ankle today and tomorrow December 5, 2020. The LPN/LVN can reinforce teaching. Which clients should be assigned to the CNA? 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. Aplastic anemia is a rare but serious condition. 3. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. A nurse is caring for a client who has a mental health disorder. Lumbar puncture reporting a headache. d. Identifying the client by name when making a referral for home health services, 30. Incorrect: This response overlooks a potentially severe problem. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. A client with atrial fibrillation currently on a diltiazem drip. A nurse wants to find out a better way to perform oral care on unresponsive clients. d. 216, 22. b. I should call my doctor if I find it harder to concentrate 2. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. 1., 4., & 5. 3. A nurse is filling out an incident report after finding a client lying on the floor. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Which of the following actions should the nurse take? Which of the following statements should the nurse make? 1. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. Select all that apply. e. an open perineal wound, 92. Which clients should be assigned to the CNA? Incorrect: The nurse is responsible for monitoring a client. This situation is considered an external disaster which means the hospital will be expecting multiple victims. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. 3. A nurse instructs a female client about collecting a midstream urine sample. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. Obtain a client's consent a. 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. Which client would be appropriate for the RN to assign to the LPN? A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. "The client is weak on the right side, so please assist the client with dressing . 4. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. Which of the following actions should the nurse take? Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. The charge nurse knows what client would be most appropriate for this LPN? A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. d. Assault, b. The option does not say the client is terminal, in a vegetative state, or in a coma. 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. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Which of the following indications should the nurse include? 4. Try different methods of oral care on unresponsive clients to see what works best. Select all that apply. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). 208 c. I will cover the catheter so he cannot see it Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. A client with an above the knee amputation reporting phantom pain. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. & 3. d. I will begin once the client's insurance company approves discharge coverage, b. Correct: This group of clients is primarily med surgical. 3. The nurse has another priority. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. There is a possibility that a hypothermia blanket may be prescribed. Gather supplies to prepare room for isolation. d. What have you done in the past to cope with this issue? b. Wash the tablet off with alcohol and place it in a clean medicine cup Client who has multiple injuries from a motor vehicle accident. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Request a prescription for a medication to ease the client's anxiety Which prescription should the nurse question and have corrected? Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Make nursing assignments appropriate to the skill level . A nurse is adhering to standard precautions while caring for a group of clients. Which of the following findings should the nurse expect? a. 3. 4. a. b. Thus, the tasks involve successful management of the charge nurse's responsibilities. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 5. 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. 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. The unit is short one staff member and will receive a nurse from the medical surgical unit. The nurse should initiate a referral with which of the following members of the interprofessional health care team? The key word in the stem is first. Which of the following responses should the nurse make? Which of the following actions indicates that the AP understands the principles of infection control? Changing a colostomy bag. What task would be best to assign to the LPN/LVN? Select all that apply This is the most stable of the four clients which places this client last to be seen. b. In what order should the emergency department triage nurse send these clients to a room for treatment? Select all that apply. 3. The client states, "I am so nervous about what the doctor might find during the test." Sudden attacks of sleep d. Wait to discuss the behavior in the presence of others, a. 4. Which of the following items should the nurse include on the lunch tray? 4. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. 1. b. b. 1. 4. Speak to the UAP to determine what happened with the feeding. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. b. Which referral would most likely be appropriate for the nurse to make? The nurse has received the change-of-shift report. 2. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. c. One nurse lifting the client's legs as the client uses a trapeze bar This schedule may leave some clients too exhausted to visit with family. Because the charge nurse observes and weighs . Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. Which of the following findings indicates that the client is meeting this goal? Select all that apply. b. b. M2.4 Making Client Care Assignments - GECC As the RN charge nurse, you are preparing to make assignments for the oncoming shift on the medical-surgical unit. b. Talk to each nurse about concerns related to assigned clients. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. Oral surgeon Teaching about a medication Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 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 client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 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. The provider must renew a restraint prescription every 8 hr. Return any fresh linen not used for a client to the linen supply area 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 Monitor for behavioral changes. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. c. Face shield 4. d. Custard d. Message, 67. This could indicate a worsening of this client's condition. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. a. Feedback The client post PEG placement is stable. 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. 5. 5. Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47. An experienced person who can research "best practice" regarding the issue is needed. The client's self-report of pain severity c. Notify the nurse manager Incorrect: This client is exhibiting early signs of increased intracranial pressure. This client is stable and predictable. b. A client with a fractured right humerus who reports the cast is too tight. c. Review another client's similar surgical experience b. I can detect the presence of carbon monoxide by a metallic odor Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. b. I'm so sorry to hear about this c. Paraphrasing b. Providing hygiene care to a client who is HIV positive This client can wait until the others are treated. An increased temperature will have a direct effect on the brain's metabolism and function.