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Underline the adjective clause in each sentence. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). A nurse is preparing to move a client who is only partially able to assist up in a bed. c. Decreased sodium excretion c. Offer the client personal thoughts and beliefs Provides day to day direction and supervision to assigneddirect patient care staff . c. Paraphrasing Which task is appropriate for the nurse to delegate to the experienced nursing assistant? 3. So what is wrong with option #1? Which of the following interventions should the nurse include? Places the soiled linen in the floor before bagging it Assist a client to ambulate using a gait belt. e. Feed a client who had a stroke 3 months ago, 32. 2. This is the most stable of the four clients which places this client last to be seen. What was the hint? Incorrect: The nurse is responsible for monitoring a client. b. I'm so sorry to hear about this Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. 3. 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. Everyone knows there are others who can chair this committee better than me 3. Client with ureterolithiasis who requires frequent PRN pain medication. c. Lock the medication in a room and finish preparing it after returning from the emergency Ask the client to perform a return demonstration of insulin injection Incorrect: Medications are not transferred with the client to a new facility. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. The nurse suggest that the family might need to respite care services. 4. Client who is a diabetic experiencing diabetic neuropathy. 1. c. Confrontation Which of the following client statements should indicate to the nurse the need for additional teaching? b. B. In option #4, we see that the leading zero is missing from the prescription. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. Accept the client's behavior as confrontational. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. Select all that apply. Incorrect: Atrial fibrillation places the client at risk for blood clots. 4. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. Yes! Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. Channel (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 3. 2. b. Correct: This group of clients is primarily med surgical. Select all that apply. 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. Disconnect client's nasogastric (NG) tube suction to allow ambulation. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. 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. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? Phone report to the receiving nurse. This is an appropriate and safe action for the unlicensed nursing assistant to do. 3. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Convenience for the nursing staff or the client's family Injuries from a motor-vehicle accident can be life threatening. 5. 3. Which of the following actions is an example of a violation of confidentiality? Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. Determine which personnel could be sent to the command center. They are more direct when discussing issues Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Encourage the client to be more cooperative. 1. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. 2. Evaluate client's safety risk factors. Client with a T-5 spinal cord injury beginning rehabilitation therapy. A person can be designated to make medical decision in the event the client cannot. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. The third client would be the one needing a dressing change. 3. Return any fresh linen not used for a client to the linen supply area 2. A client with exacerbation of COPD reporting dyspnea. 3. c. Depression The nurse should not be assigned to provide care if impairment is suspected. Aplastic Anemia Support Group. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. Pain Correct: Communication is important in delegation, as is follow-up. b. Assess the client Select all that apply d. I decline this opportunity at this time, b. Which task should the nurse take responsibility for completing? The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Provide a between meal supplement to the client. 4. A client diagnosed with rheumatoid arthritis needing discharge teaching. The client attempted to climb over the side rails and fell d. Move to the opposite side of the pack and open the fourth flap, 54. c. The client was restless and trying to get out of the bed all evening Therefore, this client would not be a priority over a client who may be experiencing a MI. It contains a blank and is followed by four answer choices. b. c. Helping the client into the shower If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. }? benefactor of the world. A client post pacemaker insertion, awaiting discharge instructions. b. Urinary frequency for several days Limit the client's fluid intake in the evening c. Rephrase statements the client does not hear Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. c. I will complete the smoking cessation program I started Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. Change the subject when the client behaves defiantly It also helps the client deal with issues that are important to him), 19. Wears a gown when entering the room of a client who requires contact precautions Clients over the age of 65 must have a saline lock according to facility policy Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 3. c. Physical therapist 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. butter, which contain 16 g of protein, 7 g of carbohydrates, Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. d. Bend at the knees when picking up an object, 99. a. When the licensed person cannot determine this, the task should not be delegated. The body needs vitamin B12 to make red blood cells. c. I should purchase a carbon monoxide detector for my home One nurse lifting as the client pushes with his feet A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. d. Highly concentrated urine, 91. a. 5. 4. The client says, "go away, no one can help me." 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. Hearing loss 3. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. Correct: Hot water may damage dentures so intervention is needed. 2. Notify clients that the disaster plan has been put into effect. Report of feeling pressure 3. There may be a good reason that the tray was not served. 3. Lisinopril 20.0 mg PO daily Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. 4. a. I wish I didn't have to attach the electrodes to my skin A nurse is assessing a client who is experiencing prostatic hypertrophy. 3. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Pick up the tray and tell the UAP that they didn't do a good job. 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. This service began with the client's admission to the hospital This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). The client must understand the need for restraints Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. 2. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Select all that apply 3. with this question, the nurse is using which of the following communication techniques? b. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. 1. Documentation is a communication tool for the interprofessional health care team. Inform the client of the need to avoid irritants such as carbonated beverages. Tenderness over the symphysis pubis This would be an acceptable task to assign to the UAP. Select all that apply Which of the following items should the nurse offer the client? Identify and assess each incoming client. c. Do not eat or drink anything the morning of the test This is not a situation that requires the LPN to notify the primary healthcare provider. The situation should be explored before bringing the supervisor in on the situation. Incorrect: The RN is responsible for teaching. A nurse is developing a plan of care for a client who practices Islam. b. Relax her abdominal muscles when she lifts an object b. eminent Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Which of the following responses should the nurse make? Ask the float nurse, "Have you been drinking?" The spouse can rescind the Advance Directive if the client becomes unresponsive. 1. c. I'll clean the inside of the container with a wipe It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. What was the rationale for this plan? (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 Which group of clients should she assign to the medical surgical nurse? Notify the primary healthcare provider of transfer completion. 3. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. A float nurse arrives on the unit to assist in the care of clients for the shift. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. Most of the following sentences contain errors in the use of modifiers and comparisons. This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. 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. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 2. 2. d. The nurse has already considered alternatives to restraints, a. 3. a. Correct: The client has the right to be involved in the decision making of their care. Following the teaching, the nurse asks the client to describe one physical effect. The LPN can monitor the wound and provide care to the PEG insertion site. 1. The last client would be the one needing dietary education. b. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. A nurse is caring for a client who is postoperative following an appendectomy. d. Proceed with the preparation of the patient's surgical procedure, 15. 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. a charge nurse is making client care assignments for the day. The nurse considers various ideas submitted by team members. The nurse should initiate a referral with which of the following members of the interprofessional health care team? But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 2. 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. 2. The nursing supervisor may be able to assist with client care until another nurse can come in to work. c. Provide the client with a diet high in protein Which of the following instructions should the nurse include? Client who has multiple injuries from a motor vehicle accident. b. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 3. Question: A charge nurse is making client care assignments. Which of the following statements should the nurse make? In which situation should the nurse consult the client's advanced directive? After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? 4. C-section planning discharge, postpartum infection, mastectomy. c. Use intermittent eye contact 4. Where on the body is each type of skin found? A high concentration of carbon monoxide can cause death Notify the nursing supervisor of the situation. The other options may be correct but are not the best first action. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Lumbar puncture reporting a headache. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. A client receiving heparin injections for deep vein thrombosis. 3. Client diagnosed with Guillain-Barre' who is receiving ventilator support. Speak to the UAP to determine what happened with the feeding. This can prevent harm to client's. A nurse is caring for a client who states, "I have got to get out of this hospital! A goal for this client is to use proper body mechanics at all times. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. b. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. the nurse responds, "don't worry, no one will harm your family." During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". Ask the charge nurse to evaluate the intervention. b. e. Talking with the client's partner, 79. d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. 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. b. A nurse is caring for a client who is postoperative following abdominal surgery. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. 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. A nurse is assessing a client who has narcolepsy. Temporary urinary retention a. Complete blockage of the large intestine. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. Elderly client admitted 30 minutes ago with reports of constipation for four days. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. 4. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. 3. a. 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. d. They disclose more personal information, a. 2. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. 1. Placing a washcloth in the bathroom sink prior to cleaning. 1., 4., & 5. Correct: The client who has a cast and requires pain medication is a stable and predictable client. A nurse is planning care for a female client who has an indwelling urinary catheter. Select all that apply Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. a. I will begin 48 hr before the client's discharge Call the client's provider 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? d. Explain oral hygiene to a client receiving chemo 4. Which prescription should the nurse question and have corrected? c. Behaving defensively If you give the magnesium citrate, which is a laxative, what will happen? Notify the charge nurse of the observations. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. Correct: Traction should never be relieved without a primary healthcare provider's prescription. Send a day's worth of medications with the client to the receiving facility. Remind the client to avoid tight fitting clothes. 3. A client with atrial fibrillation currently on a diltiazem drip. A charge nurse is observing a group of newly licensed nurses. Which of the following instructions should the nurse include? Provides safe, effective delivery of patient care in . Besides yourself, there are the following staff: Your unit has 12 beds. Describe the types of machining operations that can be performed on a lathe. A cardiac step down unit has requested float staff because of multiple impending admissions. Both of these clients are terminal. Report of feeling pressure Which actions should be instituted by each unit's charge nurse? Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. To confirm the placement of the NG tube CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Which of the following actions should the nurse include in the plan? c. Explain the risks and benefits of the procedure d. Talk with the client's partner, b. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. The surgeon initially prescribes a clear liquid diet. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. a. I will keep spare crutch tips handy d. Wait to discuss the behavior in the presence of others, a. A nurse is completing discharge teaching with a client. Perform range of motion (ROM) exercises at least 2-3 times daily