Correct: The client may be experiencing a myocardial infarction and requires further assessment. (Select all that apply.) 10. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. 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. Hypotension a. Correct: Disconnecting NG tube suction is an appropriate task for the 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. d. Droplet, d. Bend at the knees when picking up an object, 98. d. Remove tea and coffee from meal trays, b. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? Soaking the dentures in hot water 3. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. Yes! A nurse wants to find out a better way to perform oral care on unresponsive clients. We see that the temperature is already elevated, which makes us worry that infection is present. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Well, do you see the q.d.? The nurse is caring for four clients. 1. a. I will keep my walker at the end of my bed Correct. Correct: Traction should never be relieved without a primary healthcare provider's prescription. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. Which of the following tasks should the nurse delegate to assistive personnel (AP)? b. I should call my doctor if I find it harder to concentrate The cleint's family asks the nurse for info about this type of care. b. Gathering needed equipment and supplies is within the scope of duties for the UAP. d. Let's wait until tonight to see if he continues his behavior, 63. Call the client's provider Provide positive feedback to the UAP. Prepare a list of clients who could quickly be discharged or transferred. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. Feedback 5. A charge nurse is making client care assignments. The charge nurse is making client assignments for a neuro-medical floor. 3. One important aspect is encouraging the flow of ideas between management and staff members. Which client can be assigned to the LPN? 4. The abdominal pain is worsening. b. It can result in muscle spasm and tissue damage. 1. There will likely be both physical and emotional injury that needs attention, which places this client third. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. A nurse is planning care for a female client who has an indwelling urinary catheter. They are more direct when discussing issues It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. 3. c. Inform the surgical team to cancel the client's surgery Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Which of the following instructions should the nurse give to the client prior to the procedure? "The client is weak on the right side, so please assist the client with dressing . A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. Which of the following types of communication breakdown does this response represent? with this question, the nurse is using which of the following communication techniques? 2. This stage involves constructive efforts on the part of the group members Client diagnosed with Guillain-Barre' who is receiving ventilator support. The LPN/LVN can reinforce teaching. The nurse does not know the skills of the new UAP. The nurse voices his concern to the charge nurse. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. c. Hallucinations at the onset of sleep, 65. A nurse is orienting a new assistive personal (AP) to the unit. Complete blockage of the large intestine. 2. 2. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 2) Assist a client to ambulate using a gait belt. Accept assignment, documenting personal concerns regarding work conditions. b. I will come back later and we can talk a. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following actions is an example of a violation of confidentiality? Aplastic anemia is a rare but serious condition. 1) Bathe a client who had an amputation 2 days ago. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. 1. Two nurses lifting the client under the shoulders PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. b. 1., 2., 3., & 4. b. 4. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) a. Broth 5. b. Urinary frequency for several days 4. 3. 1, 3 & 5. Place the client in low Fowler's position b. Massage any bony prominences to promote circulation Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. b. d. Voided 30 mL frequently, 48. a. c. Notify the nurse manager The client's self-report of pain severity, 88. d. Complete an incident report, 70. Perform catheterization when you recognize the urge to void 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 a. Each ROM movement should be repeated 5 times during the session. This is an appropriate and safe action for the unlicensed nursing assistant to do. 2. Notify the primary healthcare provider. 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. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. 2. Incorrect: This is not completely practical for everyone. 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. 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 charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Left upper forearm a. The nurse is responsible for the assessment of all vital signs of post-op clients. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. What action should the nurse implement first to ensure client safety? What is the best care assignment for this client? Ask the primary healthcare provider to suggest the best oral care procedure. If you give the magnesium citrate, which is a laxative, what will happen? Photo comes from the Greek word for light. Focusing The nurse considers various ideas submitted by team members. 2. d. Providing information, a. The LPN can monitor the wound and provide care to the PEG insertion site. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. Which of the following physiological responses to prolonged immobility should the nurse expect? Explain to the RN that all the nurses have the same number of clients. Which group of clients should she assign to the medical surgical nurse? So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. Perform range of motion (ROM) exercises at least 2-3 times daily 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. Currently, your census is 11, with one empty bed. The nurse is reviewing some clients' prescriptions. An increased temperature will have a direct effect on the brain's metabolism and function. 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 clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. A nurse who is on hormone replacement therapy. b. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. 1. This service focuses on teaching the primary caregiver to meet the client's needs The nurse would then start the 24 hour urine once the 1st void has been discarded. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. d. Custard Select all that apply leadership management of care nurse on unit is providing care for group of clients. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. 3. 4., & 5. They are able to manage tasks related to basic care. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. Select all that apply d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. c. Use an aggressive tone of voice Administer tap water enemas until clear at 6 AM. 1. e. Talking with the client's partner, 79. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day This client is stable and predictable. d. Identifying the client by name when making a referral for home health services, 30. 4. b. Place the pack on a sterile work surface Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). 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. 2. Which task should the nurse take responsibility for completing? Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. A client receiving a blood transfusion that requires monitoring. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 4. Making client care assignments As the RN charge | Chegg.com Science Nursing Nursing questions and answers Making client care assignments As the RN charge nurse, you are preparing to make assignments for the oncoming shift in the medical-surgical unit. Incorrect: This client does not have a predictable outcome. Which of the following responses should the nurse provide? 2. Select all that apply Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Describe the types of machining operations that can be performed on a lathe. 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. b. b. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. Which of the following should the nurse identify as an interpersonal variable? c. I will inspect my crutches everyday for signs of wear Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Pain 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. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. 3. Which of the following actions should the nurse take prior to administering the tube feeding? d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). 3. 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. 5. Gather supplies to prepare room for isolation. A nurse is providing care to a client who is on strict bed rest following surgery. A charge nurse is planning client activities for the day. a. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. The RN with 2 weeks' experience on the postpartum unit. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. When staff do not feel vested in any new process, there is a sense of underappreciation. Select all that apply. (Select all that apply.) 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. Select all that apply b. a. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. A nurse is caring for a client whose partner asks to speak with the nurse. 3. 2. Assist the float nurse with the clients case. c. Review the client's progress toward personal objectives Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. c. I will complete the smoking cessation program I started This would be out of the UAP's scope of practice. d. I have a set of my brothers' crutches in the basement I can also use, a. Dexlansoprazole 30 mg PO daily. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29. 1. Select all that apply. Which of the following tasks should the nurse delegate to AP? The area surrounding the insertion site feels warm to the touch, 61. 1. Decreased or suppressed respiration are priority. a. Auscultate breath should at least ever 2 hr 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). 6. A float nurse arrives on the unit to assist in the care of clients for the shift. Measure urine output when client voids. However, providing care for missing teeth would also be within the LPN scope of practice. This client can wait until the others are treated. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 2. A nurse is caring for a client who has limited hand movement. Take several shallow breaths during the procedure A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. D. 2. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Speak to the UAP first and then decide if a between meal supplement is needed. Which of the following actions is the nurse's priority? 2. So, the UAP can assist a client to brush and floss teeth. 55. Lumbar puncture reporting a headache. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. which client would be most appropriate to assign a licensed practical nurse (lpn)? 1. Provide an adaptive feeding device for the client, 50. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. 9. a. Clarification Relief of urinary retention a. Which of the following sites should the nurse plan to use to obtain the blood specimen? This client needs ongoing monitoring which is within the scope of practice for the LPN. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) c. Can you tell me why you chose me? A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." Client scheduled for a dressing change to foot ulcer.