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. Narrative interaction 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. *HURST REVIEW Qbank/Customize Quiz - Manageme, *HURST REVIEW Qbank/Customize Quiz - Adult He, *HURST REVIEW Qbank/Customize Quiz - Basic Ca, *HURST REVIEW Qbank/Customize Quiz - Fundamen, ***HURST REVIEW NCLEX-RN Readiness Exam 1***, The Language of Composition: Reading, Writing, Rhetoric, Lawrence Scanlon, Renee H. Shea, Robin Dissin Aufses, Edge Reading, Writing and Language: Level C, David W. Moore, Deborah Short, Michael W. Smith. c. Inflate the balloon when the urine flow stops A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. a. He charge nurse is making client care assignments for the evening shift. Provide an adaptive feeding device for the client, 50. Placing the traction weights on the bed to transfer the client to x-ray. a. There is a trailing zero after the prescribed dose. d. Explain oral hygiene to a client receiving chemo Which of the following info should the nurse include? Select all that apply. Triage and assign color-coded tags to each client. What interventions can the nurse delegate to the LPN/VN? Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. 2. 5. 3. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. A nurse is having difficulty caring for a client due to variables affecting the communication process. 3. b. Massage any bony prominences to promote circulation 1. The nurse would then start the 24 hour urine once the 1st void has been discarded. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Ask the client to perform a return demonstration of insulin injection Which of the following pieces of PPE should the nurse remove first? LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Which client should the nurse assess first? This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Incorrect: This group of clients needs specific teaching. 2. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. 2. d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. d. I have a set of my brothers' crutches in the basement I can also use, a. c. I suggest you talk with a mental health counselor about your concerns a. Bathe a client who had an amputation 2 days ago Risperidone .5 mg PO daily Feed the client after warming the food. & 6. The women's health charge nurse is making assignments for the next shift. Administer tap water enemas until clear at 6 AM. Currently, your census is 11, with one empty bed. B. Which clients should be assigned to the CNA? A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. Occupational therapist Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. A charge nurse is making client care assignments. "Please explain what you mean by the word 'nervous'.". A client on a surgical unit frequently quarrels with the staff. The primary healthcare provider may have suggestions but this is not the best first action. a. Document what the nurse believes was the cause of the ulcer development Which action should the nurse interrupt the UAP from performing? If a sentence is already correct, write CCC. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. b. A nurse is caring for a client who has a hip fracture that requires surgical repair. The body needs vitamin B12 to make red blood cells. 2. Changing the subject a. The charge nurse must triage and assign clients to appropriate staff. c. I will complete the smoking cessation program I started A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. 6. 1. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. Speak to the UAP first and then decide if a between meal supplement is needed. b. eminent b. I will call the doctor and get the prescription 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? Discuss the issue with the leader of the "best practices" committee. The client can indicate desire for Do Not Resuscitate (DNR). Perform catheterization when you recognize the urge to void Incorrect: The concern here is the client being fed their meal. 4. The supervisor can only send one LPN/LVN to the floor. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? 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. a. 1. 2. 3. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Incorrect: This response overlooks a potentially severe problem. Gown d. I will begin once the client's insurance company approves discharge coverage, b. A nurse is filling out an incident report after finding a client lying on the floor. This is the most stable of the four clients which places this client last to be seen. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day 4. 4. Elevating the head of the bed 30- 40 for the client post thoracotomy Prior to turning feeding back on, tube placement needs to be verified. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Select all that apply. The RN with 10 years' experience pulled from the ER. 5. Aplastic anemia is a rare but serious condition. Remember airway, breathing and circulation (ABCs). Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. A nurse is admitting a client from a long-term care facility. 2. d. Go to employee health services, b. Assist the float nurse with the clients case. 4. What action should the nurse take after mistakenly administering the wrong medication? Call the client's provider 4. 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. 3. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? Select all that apply. A client who is disoriented and awaiting transfer to a long-term care facility. Sudden attacks of sleep Speak to the UAP to determine what happened with the feeding. d. principal. Cystogram reporting burning on urination. Incorrect: The nurse is responsible for monitoring a client. c. Decreased sodium excretion 4. What task would be best to assign to the LPN/LVN? b. This should not be delegated to the LPN/LVN. b. b. 1. This is an appropriate and safe action for the unlicensed nursing assistant to do. 4. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. A client with atrial fibrillation currently on a diltiazem drip. Female client stating she has been raped. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 4. a. Soaking the dentures in hot water b. Assess the client which of the following actions should the nurse perform? Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. Plan all care to be completed in early morning to allow afternoon for visitation. b. 2. The nurse did not trust the new UAP. Correct. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. 2. c. I'll need to shave the hair off the skin where I place the electrodes A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Change the subject when the client behaves defiantly Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Based on this information,what should the nurse do? Determining the client's length of stay Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). The nurse has received the change-of-shift report. d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. Monitor client for pain while assisting with ambulation. c. Include intact skin at the wound edges in the culture The charge nurse is planning assignments on a medical unit Which client A client diagnosed with rheumatoid arthritis needing discharge teaching. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 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. Nothing will get passed the complete blockage. Convenience for the nursing staff or the client's family 3. and 16 g of fat. A nurse receives a client care assignment from the charge nurse that he believes is unfair. a. Clarification Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. d. Perception d. Voided 30 mL frequently, 48. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. A nurse is caring for a client in the orientation phase of the nurse-client relationship. We see that the temperature is already elevated, which makes us worry that infection is present. b. 3. 1., 2., 4., & 5. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Which of the following statements should the nurse make? c. Can you tell me why you chose me? A nurse who is 10 weeks pregnant. Which of the following actions is an example of a violation of confidentiality? 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. Temporary urinary retention Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. This is likely cholelithiasis, which will need to be checked out. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 2. Teach caregivers memory enhancement aids. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Reach around the pack and open the top flap away from the body, 53. b. Verbalize understanding of how the client feels Ask the RN why the assignment is too heavy. 5. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. 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. What have you done in the past to cope with this issue? 2. b. The RN with 5 years' experience in the Labor and Delivery unit. 1. Client diagnosed with inoperative brain tumor who is confused. The client with cystitis is stable and has a predictable outcome. This task cannot be delegated to the LPN/LVN. 3. Feedback A charge nurse is making client care assignments for the day. which Question: A charge nurse is making client care assignments. Select all that apply Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. 2. b. Denial If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Select all that apply A nurse enters an older adult client's room to insert a saline lock. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. 1. 7. Injuries from a motor-vehicle accident can be life threatening. 5. 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. Allow the UAP to work without supervision. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? The nurse should initiate a referral with which of the following members of the interprofessional health care team? (Select all that apply.) 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. Which of the following actions should the nurse take? 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. Correct. The client is reporting anxiety, discomfort, and a feeling of bloating. A client requesting assistance packing his belongings for discharge later today.. a. 76. c. I will cover the catheter so he cannot see it A practical guide to making patient assignments in acute care Which of the following responses should the nurse make? Notify the primary healthcare provider. A float nurse arrives on the unit to assist in the care of clients for the shift. 1. a. 4. c. The client was restless and trying to get out of the bed all evening c. Leave a nightlight on in the client's room The nurse should not lecture, scold or argue with the float nurse. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Client with chronic emphysema experiencing mild shortness of breath. Which of the following responses should the nurse provide? (Select all that apply) a. 2. Semi-formed stools are great news! Removing the client's dentures D. Most of the following sentences contain errors in the use of modifiers and comparisons. 1. 4. 2. Handoff and Nursing Report Sheet. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. b. Everyone knows there are others who can chair this committee better than me a. Auscultate breath should at least ever 2 hr 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. What is the major histological difference between thick and thin skin? Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse? 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. 3. 1. A client with exacerbation of COPD reporting dyspnea. This protein is released by cells in the stomach. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 1. Perform range of motion (ROM) exercises at least 2-3 times daily 1. 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. A client receiving a blood transfusion that requires monitoring. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. Use double bagging to remove soiled linen from the client's room
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