2. e. Talking with the client's partner, 79. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. Select all that apply a. 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. Which of the following actions is the priority for the nurse to include in the client's plan of care? 3. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Which of the following responses should the nurse make? 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. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. c. Why are you crying? Correct: Did you notice the hint? 1., 4., & 5. Which of the following types of torts has the nurse committed? This action is a defensive intervention, and does not address the quarrelsome behavior. 3. Place in priority order. b. Which of the following actions should the nurse take? The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. The nurse is using which level of communication at this time? Underline the adjective clause in each sentence. Which of the following statements should the nurse make? d. Transporting a cerebrospinal fluid specimen to the lab Explore the client's feelings Which of the following sites should the nurse plan to use to obtain the blood specimen? Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. A client with COPD complaining of shortness of breath on exertion. A nurse is caring for a client who is postoperative. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). c. I will inspect my crutches everyday for signs of wear A nurse is teaching a client about carbon monoxide poisoning. a. I will keep spare crutch tips handy 3. 3. c. Changing a dressing, 78. Gown The facility has insurance that will cover malpractice litigation c. Depression c. Blood-tinged urine 3. d. Services are centered in long-term care facilities, a. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 212 c. Offer the client personal thoughts and beliefs Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". 3. 2. Changing the subject 1., 2., & 5. a. A nurse asks a client to share personal stories. Client who is a diabetic experiencing diabetic neuropathy. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Administer sodium polystyrene sulfonate enema. b. Irrigate the NG tube with 100 mL of sterile water a. I will begin 48 hr before the client's discharge Which of the following pieces of PPE should the nurse remove first? An increased temperature will have a direct effect on the brain's metabolism and function. Which clients could be assigned to an LPN? a. 5. Only the state Board of Nursing can legally determine the LPN's scope of practice. 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. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Sit side-by-side with the client a. Have another nurse guard the medication preparations until the nurse returns a. A nurse is caring for a client who has limited hand movement. 4. The charge nurse might not have realized all the responsibilities of taking this team of clients. This client is at a high risk of infection. What task would be best to assign to the LPN/LVN? b. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. The nurse has received the change-of-shift report. Turn on local news for up-to-date information on the train derailment. 1. Which of the following infection-control precautions should the nurse use caring for this client? Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Notify the nursing supervisor of the situation. Who should the nurse see first? A charge nurse is making assignments for an oncoming shift. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? 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. b. I will keep the fluorescent ceiling light on in my room at night In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. 2. c. imaginary Which of the following indications should the nurse include? Which of the following findings should the nurse expect? 1. 2. A client with atrial fibrillation currently on a diltiazem drip. Convenience for the nursing staff or the client's family c. Shivering d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. c. The restraints should promote the client's safety and prevent injuries 4. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Nothing by mouth (NPO). c. I'll wear low heeled shoes from now on The first vital sign check was performed by the nurse. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. Give magnesium citrate 296 mL at 3 PM today. Which of the following findings should the nurse identify as a safety risk? c. Take the client to the bathroom every 2 hr Although this will require assessment, this client is not the priority at this time. e. Feed a client who had a stroke 3 months ago, 32. e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. c. One nurse lifting the client's legs as the client uses a trapeze bar Plan all care to be completed in early morning to allow afternoon for visitation. d. Perception Select all that apply. 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. Based on these findings, to which of the following providers should the nurse request a referral for the client? Which of the following is the priority action by the nurse? d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. b. I will begin once the client's discharge order is written However, there are some basic points which are standard among all facilities. d. Move to the opposite side of the pack and open the fourth flap, 54. 1. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. 2. b. a. d. The nurse has already considered alternatives to restraints, a. b. Select all that apply. The nurse considers various ideas submitted by team members. 2. This stage involves constructive efforts on the part of the group members 3. 3. The charge nurse is planning the staff assignments for the clients on a neurological unit. b. I'll do exercises that strengthen my abdominal muscles Elderly client admitted 30 minutes ago with reports of constipation for four days. 1. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. c. Explain the risks and benefits of the procedure Include any relevant statements the client made about the ulcer b. Focus on the client's present circumstances instead of his personal stories d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. e. Dysuria, 49. Determining the client's length of stay Which of the following responses should the nurse make? Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. Which of the following actions should this nurse take? Sudden attacks of sleep Which of the following methods should the nurse plan to use? A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 4. The surgeon initially prescribes a clear liquid diet. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. 6. The nurse is focusing on which of the following elements of the communication process? A charge nurse is making client care assignments. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter (Select all that apply.). b. Grape juice Remember, pick the killer answer first! A charge nurse is observing a group of newly licensed nurses. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. b. Soaking the dentures in hot water A list of current medications is sent to the facility. Remember airway, breathing and circulation (ABCs). Incorrect: Is phantom pain something that is unexpected with above the knee amputations? The client attempted to climb over the side rails and fell Which of the following instructions should the nurse include? The client receives home health care and spends most of his day in a reclining chair. It's unfortunate that I have to be in the hospital for this treatment 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. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. Drag and Drop the items from one box to the other. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. The nurse voices his concern to the charge nurse. b. a. Richied5864 Richied5864 . Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Lumbar puncture reporting a headache. A nurse is filling out an incident report after finding a client lying on the floor. Removing the client's dentures The primary healthcare provider may have suggestions but this is not the best first action. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. 3. Announce the new changes at the monthly staff meeting. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. A nurse is caring for a client who has a mental health disorder. A nurse has just finished a wound irrigation for a client who requires contact precautions. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. c. Respite care helps relieve pain and promote comfort What action should the nurse take after mistakenly administering the wrong medication? Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. a. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. Placing the traction weights on the bed to transfer the client to x-ray. & 3. 1. 76. 3. 77. 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. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. The nurse has just completed a 12 hour shift. Notify the charge nurse of the observations. Which task should the nurse take responsibility for completing? e. Throw rugs, 40. 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. b. b. Which of the following of Erikson's developmental stages should the nurse consider in the planning? 4. In what order should the emergency department triage nurse send these clients to a room for treatment? a. 4. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 1. Battery d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. Which of the following client statements should indicate to the nurse the need for additional teaching? Use adult diapers to prevent frequent clothing changes The LPN can monitor the wound and provide care to the PEG insertion site. A nurse is caring for a client who is about to have a colonoscopy. 2. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? A nurse is engaging in relationship counseling with a male client. A person can be designated to make medical decision in the event the client cannot. Therefore, this client would not be a priority over a client who may be experiencing a MI. A nurse is performing care activities for a client in the zone of touch that requires his consent. 2. A nurse is caring for a client who has a hip fracture that requires surgical repair. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. This could cause a medical emergency. 3. Of my three brothers and sisters, my sister Giselle has the best sense of humor. The abdominal pain is worsening. Wrapping the dentures in tissue while the client sleeps Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. a. 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. Ask for any staff objections to rearranging work hours. c. Inform the surgical team to cancel the client's surgery c. Leave a nightlight on in the client's room These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. Incorrect: The nurse is responsible for evaluating a client. The report should contain consequences. This task cannot be delegated to the LPN/LVN. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. a. I'll provide more stimulation in his environment 4. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. 1., 2., 3., & 4. Which of the following should the nurse identify as an interpersonal variable? Something new could have occurred with the clients, making the assignments too heavy. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 1, 3 & 5. 1. e. The urge to move the legs when trying to sleep, 66. A home health nurse is conducting a home safety assessment for an older adult client. 3. c. Lock the medication in a room and finish preparing it after returning from the emergency c. I suggest you talk with a mental health counselor about your concerns Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Incorrect: The RN is responsible for teaching. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. Read all the current literature related to oral care on unresponsive clients. Incorrect: The concern here is the client being fed their meal. 3. c. Hand-off technique c. I'll need to shave the hair off the skin where I place the electrodes Which of the following tasks should the nurse delegate to assistive personnel (AP)? Document current functional status assessment one of the licensed practical nurses Get the answers you need, now! b. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary.