d. Lean back in the chair, b. 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 Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Also, making a surgical bed for the client returning from surgery is a basic procedure. They are likely to wait for others to initiate conversation (Select all that apply.). Which of the following tasks should the charge nurse reassign to a licensed nurse? a. I will wear gloves when removing food from the freezer 1. What is the major histological difference between thick and thin skin? 4. 3. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. d. They disclose more personal information, a. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following infection-control precautions should the nurse use caring for this client? b. Summarization The nurse also needs to be aware of the color and amount of urine voided. b. Wash the area of the puncture thoroughly with soap and water 3. This client needs careful monitoring and specialized care. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. D. Start MgSO4 at 3g/hr IV Incorrect: The nurse is responsible for monitoring a client. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. 3. 6. The client's self-report of pain severity, 88. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. A person can be designated to make medical decision in the event the client cannot. In what order should the nurse see the clients? Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. b. What is the primary factor for the charge nurse to consider when delegating care? Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. Select all that apply 28 week gestation of bed rest, postpartum with HELLP syndrome, breast reconstruction. d. Custard Assist a client to ambulate using a gait belt c. I will place an area rug at the entry of my bathroom 1. c. Offer the client personal thoughts and beliefs Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. Teaching about a medication For which of the following tasks should the nurse wear protective eye equipment. 4. Which of the following client statements should indicate to the nurse the need for additional teaching? This service began with the client's admission to the hospital d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) Determine caregiver's stress level and coping strategies. c. Use an aggressive tone of voice Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. (Select all that apply.) This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. 1. Provides day to day direction and supervision to assigneddirect patient care staff . 1. Relief of urinary retention a. 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 actions is an example of a violation of confidentiality? A nurse is caring for a client who has limited hand movement. Asking for an explanation 3. a. b. eminent 3. The nurse does not know the skills of the new UAP. Explain oral hygiene to a client receiving chemotherapy The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. This situation is considered an external disaster which means the hospital will be expecting multiple victims. Incorrect: Informing is the same thing as teaching. Disconnect client's nasogastric (NG) tube suction to allow ambulation. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. The surgeon initially prescribes a clear liquid diet. Refuse the delegated intervention. Suggest splitting the shift with another nurse. 2. Which of the following statements should the preceptor make? The third client would be the one needing a dressing change. & 4. Dr. Frankenstein had seen himself as a(n) ?\underline{? c. Can you tell me why you chose me? d. Anger, b. c. Tie linen bags securely at the top A client with COPD complaining of shortness of breath on exertion. Only the state Board of Nursing can legally determine the LPN's scope of practice. The client was lying on the floor next to his bed 6. Increased insulin production IV of D5 NS at 75 mL/hour with a 20 gauge catheter. A goal for this client is to use proper body mechanics at all times. Client to receive dietary education. Remember, pick the killer answer first! 1. Focus on the client's present circumstances instead of his personal stories 3. The charge nurse needs additional information to make a decision. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. c. I suggest you talk with a mental health counselor about your concerns Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Review a low-sodium diet for a client who has hypertension. c. Nonfat milk Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. d. When asking if the client took his medications this morning, 82. 2. Incorrect: The concern here is the client being fed their meal. 2. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. Which of the following responses should the nurse provide? a. Assist the float nurse with the clients case. What is the appropriate assignment? A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. The nurse has just completed a 12 hour shift. a. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. The client with chronic emphysema has expected shortness of breath. 3. A medical-surgical LPN has been sent to a short-staffed pediatric unit. The healthcare team should recognize the client as the center of the team. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. a. Which of the following findings associated with urinary retention should the nurse expect? Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. 2. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. 2. Elevating the head of the bed 30- 40 for the client post thoracotomy Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. A nurse is caring for a client who is postoperative following an appendectomy. a. 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. b. Numbness the nurse responds, "don't worry, no one will harm your family." Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. Tenderness over the symphysis pubis 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Temporary urinary retention a. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Well, do you see the q.d.? The RN with 10 years' experience pulled from the ER. Reporting laboratory findings to a member of the client's family Which of the following statements should the nurse identify as an indication that the client understands the instructions? b. Massage any bony prominences to promote circulation Incorrect: The RN is responsible for collecting data. b. 4. 4. Sit side-by-side with the client Which of the following types of torts has the nurse committed? c. Helping the client into the shower Change the subject when the client behaves defiantly Thoracentesis reporting shortness of breath. Sudden attacks of sleep What is the best response by the charge nurse? 2. 4. Because the charge nurse observes and weighs . 4. This is not a situation that requires the LPN to notify the primary healthcare provider. The client is reporting anxiety, discomfort, and a feeling of bloating. 2. (Select all that apply.). 3. c. The client's culture Select all that apply. Besides yourself, there are the following staff: Your unit has 12 beds. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Bargaining 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. Which of the following of Erikson's developmental stages should the nurse consider in the planning? A client receiving a blood transfusion that requires monitoring. Education What is the best first action for the nurse to take in order to achieve this goal? 3. 1. Encourage client to express grief related to loss of independence. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. The nurse should call for immediate help so that a safe care environment is maintained for all clients. b. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Focusing - Assisting a client to ambulate using a gait belt. Select all that apply Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. 5. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. 1. The body needs vitamin B12 to make red blood cells. Airborne d. Talk with the client's partner, b. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. 1. Allow the UAP to work without supervision. Which of the following RNs should not be assigned to this baby? Which of the following statements by the student indicates understanding of the discussion? Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. Administer sodium polystyrene sulfonate enema. a. This can prevent harm to client's. c. Contact b. Therefore, this would not be the most appropriate nurse to assign to this client. A nurse has just finished a wound irrigation for a client who requires contact precautions. 2. A nurse instructs a female client about collecting a midstream urine sample. 76. 1. 1. d. I have a set of my brothers' crutches in the basement I can also use, a. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. b. 3. Correct: The medical nurse can be assigned to this client. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. We see that the temperature is already elevated, which makes us worry that infection is present. b. Dons gloves to empty a urinary drainage device a. Incorrect: This group of clients needs specialized care. 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. 1. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. (Select all that apply.) This would be out of the UAP's scope of practice. 4. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. So, the UAP can assist a client to brush and floss teeth. a. Based on this information,what should the nurse do? b. Vital sign measurement B. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures A nurse receives a client care assignment from the charge nurse that he believes is unfair. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. 4. The unit is short one staff member and will receive a nurse from the medical surgical unit. Make referrals to community services. 4. d. Perception Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? "The client is weak on the right side, so please assist the client with dressing . Drag and Drop the items from one box to the other. In the following sentences, circle each incorrectly used lowercase letter. A nurse has completed an informed consent form with a client. The nurse should use close-ended questions when assessing which of the following factors? e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. 2. 3. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. The nurse is using which level of communication at this time? 2. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. 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. Which of the following actions by the nurse is considered an indirect nursing care activity? Gown A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Teaching insulin self administration to a diabetic client. The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. The client would develop severe cramping. c. One nurse lifting the client's legs as the client uses a trapeze bar c. Request a tray without pork 6. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. b. If the client is unstable, the nurse would retain the role of measuring the vital signs. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? b. c. Open the right flap with the left hand Which of the following statements should the nurse identify as an indication that the client needs further teaching? The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? leadership management of care nurse on unit is providing care for group of clients. 4. The nursing supervisor may be able to assist with client care until another nurse can come in to work. Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. Relax her abdominal muscles when she lifts an object A nurse is assessing a client at a follow-up clinic for acute low back pain. A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. c. Review another client's similar surgical experience c. Hand-off technique The LPN/LVN can reinforce teaching. 4. A high concentration of carbon monoxide can cause death Select all that apply a. I'll urinate a little then stop b. This task cannot be delegated to the LPN/LVN. In which situation should the nurse consult the client's advanced directive? d. What have you done in the past to cope with this issue? a. The charge nurse must triage and assign clients to appropriate staff. The expected standard of care was strict bed rest), 96. 5. 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. Notify the surgeon that the client wishes to withdraw informed consent for the procedure 1. 4. c. Raised toilet seats The nurse has another priority. A nurse asks a client how he is feeling. In order to reorganize staffing, the nurse manager should initiate which action first? Following a large hurricane, multiple clients arrive at the emergency room for treatment. c. Use intermittent eye contact b. a. I wish I didn't have to attach the electrodes to my skin The option does not say the client is terminal, in a vegetative state, or in a coma. 2. Comatose client with end stage chronic obstructive pulmonary disease. This client is not the nurse's first priority. a. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). An experienced person who can research "best practice" regarding the issue is needed. December 5, 2020. The charge nurse is making client assignments for a neuro-medical floor. Incorrect: The nurse retains the responsibility for the delegated task. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87.
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