Correct: The unlicensed nursing assistant should not turn tube feedings off or on. d. Discard the prepared medications and begin again after returning, d. I will wear synthetic clothing and woolen socks when using my oxygen (woolen and synthetic materials can generate static electricity and oxygen is a flammable gas - the client should wear cotton), 73. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Which of the following interventions should the nurse include? c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day a. Provide a between meal supplement to the client. This should not be delegated to the LPN/LVN. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. b. An Advance Directive includes a Living Will and a Medical Power of Attorney. This is not a situation that requires the LPN to notify the primary healthcare provider. a. c. I should purchase a carbon monoxide detector for my home A nurse is planning care for a female client who has an indwelling urinary catheter. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. b. a. The option does not say the client is terminal, in a vegetative state, or in a coma. This client should report an improved respiratory, not shortness of breath. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. the nurse responds, "don't worry, no one will harm your family." The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. The surgeon initially prescribes a clear liquid diet. Decreased or suppressed respiration are priority. 4. The primary healthcare provider may have suggestions but this is not the best first action. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. 3. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. c. The emphasis is on the client's complete recovery from the illness or injury 3. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Select all that apply Yes! a. Which action by an unlicensed nursing assistant would require the nurse to intervene? a. Which of the following actions should the nurse take? A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which task should the nurse take responsibility for completing? Determining the client's length of stay 4. Fruity breath. Which client should the nurse assess first? a. A nurse is discussing the norming stage of the group development process with a student nurse. Which client would be appropriate for the RN to assign to the LPN? Which of the following info should the nurse include? a. The client is considered unstable until assessed by the nurse. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Which prescription should the nurse question and have corrected? This could indicate a worsening of this client's condition. Client with cast to right leg requiring pain medication. Relax her abdominal muscles when she lifts an object c. Washes and rinses her hands for 10 seconds 1. Risperidone .5 mg PO daily A list of current medications is sent to the facility. Incorrect: This response overlooks a potentially severe problem. 4. c. I will inspect my crutches everyday for signs of wear Additionally, off-duty personnel may be needed and should be alerted to stand by; however, the command center alone makes the determination whether extra personnel should be called in, or if it would put more individuals in jeopardy. This is the most stable of the four clients which places this client last to be seen. 2. The client must understand the need for restraints A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). c. Offer the client personal thoughts and beliefs 2. 1. 3. The nurse should do this when repositioning is needed. The nurse could definitely be part of the committee. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. b. A nurse is caring for a client who is postoperative. 3. An LPN/VN has been floated to the emergency room following a chemical plant explosion. c. Notifying the provider of physical exam findings This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. Which of the following findings associated with urinary retention should the nurse expect? Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. a. Remember, pick the killer answer first! 2. Change the subject when the client behaves defiantly A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? Thus, the tasks involve successful management of the charge nurse's responsibilities. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. b. A nurse who is breastfeeding her 4 month old. 4. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. This service began with the client's admission to the hospital b. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. c. Industry vs inferiority 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. Client reporting a headache and has a fruity breath. 55. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. b. a. 1. A nurse has just finished a wound irrigation for a client who requires contact precautions. 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. 2. 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. Correct: This group of clients is primarily med surgical. 4. Warm the feeding solution to the body temperature But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. 1., 4., & 5. Which of the following actions should the nurse include in the plan? Compartment syndrome could be developing which can impede circulation and cause nerve damage. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. b. b. The cause of the fall may be cardiac, but the question does not indicate this. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. A nurse has completed an informed consent form with a client. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. The charge nurse knows what client would be most appropriate for this LPN? 2. Which of the following findings indicates that the client is meeting this goal? This client needs careful monitoring and specialized care. Encourage clients and families to develop mutually appropriate visitation times. Notify the primary healthcare provider of transfer completion. b. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Female client stating she has been raped. 3. Point out inconsistences in the client's behavior a. Elderly clients have special fluid and electrolyte issues after a fall. 3. All these clients have a GI problem. 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. A nurse is assessing a client who has narcolepsy. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. What is the primary factor for the charge nurse to consider when delegating care? Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Refuse the delegated intervention. a. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? Drag and Drop the items from one box to the other. 3. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. 1. A nurse is developing a plan of care for a client who practices Islam. A client who is disoriented and awaiting transfer to a long-term care facility. b. Administer tap water enemas until clear at 6 AM. 1. Lisinopril 20.0 mg PO daily d. Go to employee health services, b. Remove all metal necklaces d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. c. Confrontation For which of the following tasks should the nurse wear protective eye equipment. It would not be appropriate to overload this new employee with extra work. It happened so long ago - just get over it!" The below statement corresponds to a numbered sentence in the passage. This is normal for clients with hemorrhoids. UAPs can assist with elimination and are taught how to measure output. Both of these clients are terminal. Documentation of what occurred, and the client's assessment is required in the nurse's notes. They are more direct when discussing issues To which of the following rooms should the nurse assign the client? d. Services are centered in long-term care facilities, a. The surgeon initially prescribes a clear liquid diet. 4. 2. d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. 3. A nurse is preparing to move a client who is only partially able to assist up in a bed. During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate? 1. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. 76. Twist at the waist when she moves an object to one side 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. Stand directly in front of the client This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). The best practice committee utilizes current research in their recommendations. This would be out of the UAP's scope of practice. Irrigate a client's ear canal. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. b. 1. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. A nurse is caring for a client within the intimate zone of the client's personal space. Select all that apply Incorrect: This would unnecessarily alarm the clients. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. Convenience for the nursing staff or the client's family 1. Which of the following info should the nurse include? Well, do you see the q.d.? Perform range of motion (ROM) exercises at least 2-3 times daily Encourage the client to use self-exploration Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. Which of the following responses should the nurse make? Accept assignment, documenting personal concerns regarding work conditions. butter, which contain 16 g of protein, 7 g of carbohydrates, a. A nurse is providing discharge teaching for a client who requires home oxygen therapy. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. Nurses dependent on drugs or alcohol can harm clients. Select all that apply. c. I will place an area rug at the entry of my bathroom This can prevent harm to client's. Correct: Did you notice the hint? 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. b. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. However, there are some basic points which are standard among all facilities. d. The nurse has already considered alternatives to restraints, a. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". The women's health charge nurse is making assignments for the next shift. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. c. Assist the client to the floor and begin mouth-to-mouth A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Briefly assess every client. What is the appropriate assignment? Assessing this client and titrating the diltiazem requires the skills of an RN. 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. Dexlansoprazole 30 mg PO daily. When staff do not feel vested in any new process, there is a sense of underappreciation. 4. Select all that apply. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. c. I'll clean the inside of the container with a wipe Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Select all that apply There may be a good reason that the tray was not served. A cardiac step down unit has requested float staff because of multiple impending admissions. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? 3. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 3. 5. 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. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. The nurse is using which level of communication at this time? d. When asking if the client took his medications this morning, 82. A nurse is teaching a client about the physical effects of chemotherapy. 6. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 1., 2., 3., & 4. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. d. Place the tablet directly into a medication cup, 36. Could you try contacting a support group This client is at a high risk of infection. The RN with 2 weeks' experience on the postpartum unit. (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 5. 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. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. a. Gloves Removing the client's dentures Also, making a surgical bed for the client returning from surgery is a basic procedure. In option #4, we see that the leading zero is missing from the prescription. 6. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Furosemide 40 mg PO q.d. The RN with 10 years' experience pulled from the ER. Two nurses lifting the client under the shoulders The nurse on a large surgical unit needs to evaluate several clients returning from procedures. 4. b. A client requesting assistance packing his belongings for discharge later today..
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