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

d. Anger, b. Which of the following actions should the nurse take? Everyone knows there are others who can chair this committee better than me Everything will be okay Discussing a client's surgical procedure with the nurse manager c. Malpractice The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. d. Establishing the client's secondary medical diagnoses, b. Placing the traction weights on the bed to transfer the client to x-ray. A nurse is caring for a client who has a wound infection. b. I will keep the fluorescent ceiling light on in my room at night In what order should the emergency department triage nurse send these clients to a room for treatment? 4. b. I'll do exercises that strengthen my abdominal muscles Select all that apply The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Correct. Ask the float nurse, "Have you been drinking?" b. Irrigate the wound with an antiseptic prior to obtaining the specimen Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. When a family member asks how respite care can help, which of the following responses should the nurse provide? 1. 2. A nurse is planning care for a female client who has an indwelling urinary catheter. b. 4. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. This includes medication enemas. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). 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. A client with epilepsy reporting an odd smell in the room. A nurse has just finished a wound irrigation for a client who requires contact precautions. The nurse has another priority. 2. Right forearm c. Distended bladder In which harmonic number n is the string vibrating? e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. A nurse is caring for a client who is scheduled for an elective surgical procedure. Correct: Traction should never be relieved without a primary healthcare provider's prescription. d. What have you done in the past to cope with this issue? Remember, pick the killer answer first! This client could be transferred with traction still maintained. Both of these clients are terminal. Which of the following actions should the nurse take first? 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. Use the tablet's packaging to pick it up from the counter 3. 4. Select all that apply which client would be most appropriate to assign a licensed practical nurse (lpn)? c. Notify the nurse manager Which of the following findings associated with urinary retention should the nurse expect? They are able to manage tasks related to basic care. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Administer tap water enemas until clear at 6 AM. A. What action should the nurse implement first to ensure client safety? b. Ask the charge nurse to evaluate the intervention. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? b. A nurse is caring for a client who has a hip fracture that requires surgical repair. c. Offering false reassurance As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. 3. Speak to the UAP to determine what happened with the feeding. Gather supplies to prepare room for isolation. 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. Notify the surgeon that the client wishes to withdraw informed consent for the procedure A nurse is caring for a client who is immobile. Underline the adjective clause in each sentence. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Drag and Drop the items from one box to the other. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. An LPN/VN has been floated to the emergency room following a chemical plant explosion. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. 5. The first vital sign check was performed by the nurse. The nurse prefers to check all vital signs on all clients. 5. 2. b. Select all that apply. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. 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. 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. d. When asking if the client took his medications this morning, 82. The reason for the UAP not feeding the client needs to be determined. 1. 3. Could you try contacting a support group 2. 2. This referral would be appropriate. Nurses dependent on drugs or alcohol can harm clients. What interventions can the nurse delegate to the LPN/VN? c. Use an aggressive tone of voice d. Bend at the knees when picking up an object, 99. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. Document what the nurse believes was the cause of the ulcer development Select all that apply a. 2. 1. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. Answer the following question to test your understanding of the preceding section: 1. They are likely to wait for others to initiate conversation A nurse is developing a plan of care for a client who practices Islam. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. 1. Checking capillary refill beneath the client's fingernail 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. d. Mask, 83. Sit side-by-side with the client Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. Monitor client for pain while assisting with ambulation. a. 2. A nurse is filling out an incident report after finding a client lying on the floor. 4. An experienced person who can research "best practice" regarding the issue is needed. The area surrounding the insertion site feels warm to the touch Incorrect: The nurse is responsible for monitoring a client. 5. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. c. Holds the soiled linen against her body while carrying it to the linen bag b. A client on a surgical unit frequently quarrels with the staff. 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. d. Voided 30 mL frequently There are a total of 10 adult clients. Assign a nursing assistant to help the client with self-care activities. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. Call the client's provider 3. d. Identifying the client by name when making a referral for home health services, 30. Administering IV pain medication to a two day post op client. Nothing by mouth (NPO). 2. Notify the board of nursing (BON) that the float nurse is an alcoholic. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. c. Do not eat or drink anything the morning of the test 4., & 5. The client's self-report of pain severity, 88. 1. a. 1. c. Hallucinations at the onset of sleep, 65. The nurse has received the change-of-shift report. The third client that should be sent back for treatment is the female client stating she has been raped. 4. Which of the following statements should the nurse identify as an indication the client needs further teaching? Pernicious Anemia Society Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Provides safe, effective delivery of patient care in . 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. 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 first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. A nurse is orienting a new assistive personal (AP) to the unit. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. Respite care provides holistic support and care for a client who is terminally ill b. I will call the doctor and get the prescription So what is wrong with option #1? It's just not the right time for me to do this a. d. 216, 22. The situation should be explored before bringing the supervisor in on the situation. To focus on effective learning with this client, which of the following interventions should the nurse use? When staff do not feel vested in any new process, there is a sense of underappreciation. (Select all that apply.) IV of D5 NS at 75 mL/hour with a 20 gauge catheter. b. Notify the charge nurse of the observations. Talk to each nurse about concerns related to assigned clients. d. Counting radial pulse 4. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. What client should the nurse assess first? It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 2. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. c. Assist the client to the floor and begin mouth-to-mouth Correct: The client may be experiencing a myocardial infarction and requires further assessment. a. I wish I didn't have to attach the electrodes to my skin The charge nurse might not have realized all the responsibilities of taking this team of clients. Client with a T-5 spinal cord injury beginning rehabilitation therapy. c. Notifying the provider of physical exam findings Asking for an explanation (Select all that apply.) Pick up the tray and tell the UAP that they didn't do a good job. Speak using his usual tone of voice b. 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. Remind the client to tell the nurse when he has to urinate This documentation should go to your manager. Which of the following physiological responses to prolonged immobility should the nurse expect? 1. Which of the following instructions should the nurse include? Which of the following statements by the nurse would provide UAP with the best directions about an assignment? b. Transfer essential medical record to the receiving facility. c. Changing a dressing, 78. Place the pack on a sterile work surface 1. b. A list of current medications is sent to the facility. c. Distended bladder Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. c. Irrigating a client's abdominal wound _________________ (magnanimous), a. generous A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. Simply accept the assignment since overtime is mandatory. Refuse the assignment, being prepared for disciplinary action. Vital sign measurement 208 Ambulating a client who is 2 days post vaginal hysterectomy b. Ask the RN why the assignment is too heavy. Only the state Board of Nursing can legally determine the LPN's scope of practice. 3. A nurse asks a client how he is feeling. The surgeon initially prescribes a clear liquid diet. b. A nurse is preparing a sterile field. Dexlansoprazole 30 mg PO daily. 3. 2. Client scheduled for breast reconstruction after mastectomy. Discuss the competency of the surgeon c. Consensus evolves in this stage Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. a. Auscultate breath should at least ever 2 hr Prepare a list of clients who could quickly be discharged or transferred. What is the best care assignment for this client? Which of the following actions should the nurse take? Determine caregiver's stress level and coping strategies. 2. a. 3. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 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. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Prior to turning feeding back on, tube placement needs to be verified. b. The nurse asks why the client needs to know this. c. Behaving defensively Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. a. I will keep my walker at the end of my bed Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. In the following sentences, circle each incorrectly used lowercase letter. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Assigning blame for the changes to administration will not help staff adjust. Handoff and Nursing Report Sheet. 1. A nurse is caring for a client within the intimate zone of the client's personal space. 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. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? a. Thoracentesis reporting shortness of breath. 3. Provide positive feedback to the UAP. Select all that apply Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? A client with exacerbation of COPD reporting dyspnea. Who should the nurse see first? Female client stating she has been raped. c. Initiate a liquid diet for the client
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