d. Talk with the client's partner, b. Notify clients that the disaster plan has been put into effect. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). A nurse is performing care activities for a client in the zone of touch that requires his consent. 1., 2., 4., & 5. 2. Correct: Traction should never be relieved without a primary healthcare provider's prescription. a. Gloves Based on the information provided in report, which client condition should be the nurse's priority? 1, 3 & 5. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. Select all that apply a. Clarification A new UAP is efficiently completing all daily assignments accurately and in a timely manner. c. Palpating for pedal edema What is the best response by the charge nurse? This can prevent harm to client's. }? benefactor of the world. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 2. 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. Incorrect: Atrial fibrillation places the client at risk for blood clots. 2. 3. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. 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. a. A high concentration of carbon monoxide can cause death This stage is when testing occurs to identify boundaries of interpersonal behaviors 3. Discarding the first urine voided by the client starting a 24 hour urine test. Call the family of a client suffering from dementia to discuss long term care placement. A nurse is assessing a client at a follow-up clinic for acute low back pain. It also helps the client deal with issues that are important to him), 19. Provides day to day direction and supervision to assigned direct patient care staff. Which of the following actions should the nurse take? 3. 4. The charge nurse's best response is to first obtain the needed information to make the best decision. e. Feed a client who had a stroke 3 months ago, 32. 3. What would the approximate meaning of photoelectric be, based on these root words? When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. Show client who has conjunctivitis how to clean the eyes. Asking for an explanation Which of the following types of torts has the nurse committed? b. The LPN can monitor the wound and provide care to the PEG insertion site. Measure urine output when client voids. c. Confrontation This client needs ongoing monitoring which is within the scope of practice for the LPN. Encourage the client to be more cooperative. 1. Which of the following instructions should the nurse include? Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. 1. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. These are appropriate tasks for an UAP to complete. Observe the client before taking further actions c. They tend to use more verbal communication c. Use intermittent eye contact Each state BON differs in that also some have treatment programs they administer themselves. 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. 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. The client asks about his medications and their effects. A nurse is providing discharge teaching for a client who requires home oxygen therapy. Incorrect: The client does need to have food; however, there is another action that should be performed first. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. 1. Which of the following tasks should the charge nurse reassign to a licensed nurse? Which of the following actions should the nurse take to assist the client with feeding? Which of the following responses should the nurse provide? Incorrect: This client is exhibiting early signs of increased intracranial pressure. 3. Did you recognize ureterolithiasis as "kidney stones"? The area surrounding the insertion site feels warm to the touch Respite care allows the primary caregiver time away from day-to-day care responsibilities c. 214 This stage involves constructive efforts on the part of the group members 4. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. d. I shouldn't advice you about what is ultimately a personal decision, b. Which of the following instructions should the nurse include? b. b. 1. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. 2. a. a. The LPN should refuse the intervention. c. imaginary Also, making a surgical bed for the client returning from surgery is a basic procedure. 4. Select all that apply Tenderness over the symphysis pubis 3. Provide an adaptive feeding device for the client, 50. Remember, pick the killer answer first! b. (SATA) -Bathing a client who had an amputation 2 days ago. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 3. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 3. Sudden attacks of sleep Patient safety must remain the priority. Obtain a urine specimen from a client with an indwelling Foley catheter. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. Suggest splitting the shift with another nurse. 3. 2. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. c. Notifying the provider of physical exam findings EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. 1. Which nursing intervention should the charge nurse implement? Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. b. Include any relevant statements the client made about the ulcer Obtain a bedside commode for the client's use 6. What is the most appropriate action by the charge nurse? Ask for any staff objections to rearranging work hours. The client is reporting anxiety, discomfort, and a feeling of bloating. b. c. Request a tray without pork a. 1. 2. The third client that should be sent back for treatment is the female client stating she has been raped. b. Verbalize understanding of how the client feels 1. Include any relevant statements the client made about the ulcer, 64. Drag and Drop the items from one box to the other. The client was lying on the floor next to his bed d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Correct: The client has the right to be involved in the decision making of their care. Write the letter of your choice on the answer line. Which of the following communication techniques should the nurse use during this phase? It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. c. Lock the medication in a room and finish preparing it after returning from the emergency 3. Which of the following actions should the nurse take? Female client stating she has been raped. A client who is disoriented and awaiting transfer to a long-term care facility. The other options may be correct but are not the best first action. Although this will require assessment, this client is not the priority at this time. The nurse is reviewing some clients' prescriptions. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. 2. The client with cystitis is stable and has a predictable outcome. This client needs careful monitoring and specialized care. Talk to each nurse about concerns related to assigned clients. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. A client with epilepsy reporting an odd smell in the room. Cystogram reporting burning on urination. c. The emphasis is on the client's complete recovery from the illness or injury Serve food that have a hot/cold balance d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. Providing a passive response Explain administration is demanding a decreased overtime. Send a day's worth of medications with the client to the receiving facility. What was the rationale for this plan? a. d. Assault, b. Place in priority order. 4. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. There are a total of 10 adult clients. Which group of clients should she assign to the medical surgical nurse? with this question, the nurse is using which of the following communication techniques? Accept the client's behavior as confrontational. Perform the Heimlich maneuver A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. 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. b. Which of the following statements should the nurse make? Elderly client who fell and fractured the left femoral neck. a. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. b. A nurse is creating a discharge plan. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. c. I suggest you talk with a mental health counselor about your concerns Place the client in low Fowler's position The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. Which of the following client statements should indicate to the nurse the need for additional teaching? 77. A nurse is preparing to obtain a blood specimen from a client by venipuncture. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Review the action of insulin therapy Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. A nurse is caring for a client who is postoperative following abdominal surgery. d. They disclose more personal information, a. 2. Allow families unlimited visitation around the clock to meet their schedules. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Now, in Option #2, we see a dangerous prescription. _________________ (magnanimous), a. generous Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. The charge nurse must triage and assign clients to appropriate staff. Call the client's provider The key word in the stem is first. Semi-formed stools are great news! A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. 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. 3. Review a low-sodium diet for a client who has hypertension. 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. Phone report to the receiving nurse. 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. The client is considered unstable until assessed by the nurse. 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. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. b. The stem does not indicate any loss of neurological function resulting from the seizure activity. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 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. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. 3. The charge nurse on the postpartum unit is making assignments. Which of the following physiological responses to prolonged immobility should the nurse expect? What task would be best to assign to the LPN/LVN? A home health nurse is conducting a home safety assessment for an older adult client. The nurse prefers to check all vital signs on all clients. b. I should call my doctor if I find it harder to concentrate A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. 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).
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