Education 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. 2. Which of the following instructions should the nurse give to the client prior to the procedure? a. A nurse is adhering to standard precautions while caring for a group of clients. Incorrect: The RN is responsible for assessment and evaluation. c. Providing anticipatory guidance to a client in crisis You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Problems in Delegation: A Busy Day on the Floor - Quizlet Assist client to brush and floss teeth. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. A nurse is creating a discharge plan. Refuse the assignment, being prepared for disciplinary action. Answer the following question to test your understanding of the preceding section: This client will also need a lot of education regarding anti-rejection medications. Alcoholic Anonymous The client receives home health care and spends most of his day in a reclining chair. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. This determination is needed to assure client safety is being considered. d. Explain oral hygiene to a client receiving chemo Symbolic communication Confrontation should occur in the presence of a charge nurse or supervisor. & 6. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. 4. b. 1. (Select all that apply.). Alert all off-duty personnel to stand by in case of call- in. 3. b. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. 4. Ask the RN why the assignment is too heavy. Which of the following statements should the preceptor make? Checking capillary refill beneath the client's fingernail c. Review another client's similar surgical experience 5. To which of the following rooms should the nurse assign the client? Call the client's provider d. Routine acquisition of a urine specimen Oral surgeon 3. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? 4. 1. 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. c. Document in the client's medical record that she completed an incident report A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. A charge nurse is making assignments for an oncoming shift. These individuals are selected by the charge nurse, and do not have to be nurses. d. Do you think crying will help? 4. Of my three brothers and sisters, my sister Giselle has the best sense of humor. The area surrounding the insertion site feels warm to the touch, 61. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). b. Temporary urinary retention b. Discussing a client's surgical procedure with the nurse manager A person can be designated to make medical decision in the event the client cannot. In which harmonic number n is the string vibrating? In what order should the nurse see the clients? Discuss the assignment with another LPN. b. I should call my doctor if I find it harder to concentrate a. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? assignmentcafe.com - A charge nurse is making assignments for nursing 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. The body needs vitamin B12 to make red blood cells. A client receiving a blood transfusion that requires monitoring. a. I'll sit with my knees lower than my hips a. The nurse should use close-ended questions when assessing which of the following factors? c. I will begin upon the client's admission to the facility 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 instructs a female client about collecting a midstream urine sample. Select all that apply A client with an above the knee amputation reporting phantom pain. Which actions should be instituted by each unit's charge nurse? c. The restraints should promote the client's safety and prevent injuries Which task should the nurse take responsibility for completing? 1. A nurse is caring for an older client who is at risk for skin breakdown. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Which of the following responses should the nurse make? 4. a. Clarification (Select all that apply.). 3. 1. a. b. NUR 204 ATI Management of Care Ch. 1-9 Flashcards | Quizlet Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Client to receive dietary education. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. 1. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. 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. The provider must renew a restraint prescription every 8 hr. The nurse is using which of the following therapeutic communication techniques? Remind the client to tell the nurse when he has to urinate a. Elicit info from the client When staff do not feel vested in any new process, there is a sense of underappreciation. The LPN/LVN can reinforce teaching. 4. Monitor for GI upset 30 minutes after meals. b. I will bear the weight of my body on my hands d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Incorrect: The nurse is responsible for evaluating a client. A nurse is orienting a new assistive personal (AP) to the unit. b. Massage any bony prominences to promote circulation b. Which of the following actions should the nurse take? 3. a. A client requesting assistance packing his belongings for discharge later today.. b. 1. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department This referral would be appropriate. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. A nurse is having difficulty caring for a client due to variables affecting the communication process. Which client should the nurse assess first? 4. 1. Correct: Communication is important in delegation, as is follow-up. - Assisting a client to ambulate using a gait belt. 3. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Client with a T-5 spinal cord injury beginning rehabilitation therapy. However, it remains true pain for this client and the client would need intervention to help manage this pain. Incorrect: This again is assessment which is the role of the RN only. 6. 1. Refuse the delegated intervention. 1. The nurse is focusing on which of the following elements of the communication process? The nurse should call for immediate help so that a safe care environment is maintained for all clients. 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. Provide an adaptive feeding device for the client Each ROM movement should be repeated 5 times during the session. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. This client can wait until the others are treated. b. I will come back later and we can talk Twist at the waist when she moves an object to one side 2. C. Review a low-sodium diet for a client who has hypertension. 5. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Obtain a urine specimen from a client with an indwelling Foley catheter. Report of feeling pressure The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. The client says, "go away, no one can help me." Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. Nothing will get passed the complete blockage. What is the primary factor for the charge nurse to consider when delegating care? b. 2. Correct: The client who has a cast and requires pain medication is a stable and predictable client. a. A nurse is assessing a client at a follow-up clinic for acute low back pain. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 3. he charge nurse is making client care assignments for the evening shift (Select all that apply) A nurse is preparing a sterile field. 3. d. Counting radial pulse, 100. a. I will keep spare crutch tips handy c. The client was restless and trying to get out of the bed all evening The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Based on the information provided in report, which client condition should be the nurse's priority? Notify the board of nursing (BON) that the float nurse is an alcoholic. c. Offering false reassurance 5. 2. A client with atrial fibrillation currently on a diltiazem drip. Wrapping the dentures in tissue while the client sleeps A nurse is caring for a client who is postoperative following abdominal surgery. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Which of the following approaches should the nurse use when using confrontation? 1. 1. Check environment for potential safety hazards. a. b. I will begin once the client's discharge order is written Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Which of the following statements should the nurse make? A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. d. Water heater temp 54.4 C (130 F) a. 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? Drag and Drop the items from one box to the other. b. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. Assist a client to ambulate using a gait belt A nurse is caring for a client who states, "I have got to get out of this hospital! 3. Wears a gown when entering the room of a client who requires contact precautions 2. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Observe the client before taking further actions Everyone knows there are others who can chair this committee better than me The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. d. Voided 30 mL frequently Which of the following nontherapeutic communication techniques is the nurse using? c. Holds the soiled linen against her body while carrying it to the linen bag A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. This stage is when testing occurs to identify boundaries of interpersonal behaviors c. I will make sure my visitors smoke outside Which of the following actions is the nurse's priority? 2. Administer sodium polystyrene sulfonate enema. Thoracentesis reporting shortness of breath. Use the tablet's packaging to pick it up from the counter 2. b. 1., 2., 3., & 4. The Role of the Registered Nurse as Charge Nurse Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. d. I will begin once the client's insurance company approves discharge coverage, b. Drag and Drop the items from one box to the other. b. Assist a client to ambulate using a gait belt. Which of the following instructions should the nurse include? c. Depression Which of the following responses should the nurse make? 2. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. 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. Which prescription should the nurse question and have corrected? Inform the client of the need to avoid irritants such as carbonated beverages. Besides yourself, there are the following staff: Your unit has 12 beds. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. b. Which nurse should be assigned to care for this client? d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. A nurse who is breastfeeding her 4 month old. a. a.) 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. Provides day to day direction and supervision to assigneddirect patient care staff . a. 55. 1. Correct: The UAP can remind the client to do something that has already been taught by the nurse. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Make nursing assignments appropriate to the skill level . Which of the following activities should the nurse perform in this zone? A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. a. I will keep my walker at the end of my bed Providing a passive response The third client that should be sent back for treatment is the female client stating she has been raped. c. I suggest you talk with a mental health counselor about your concerns In which situation should the nurse consult the client's advanced directive? Prepare a list of clients who could quickly be discharged or transferred. e. an open perineal wound, 92. e. Feed a client who had a stroke 3 months ago, 31. . A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. a. This would be out of the UAP's scope of practice. d. Place the tablet directly into a medication cup, 36. Have a pen and paper handy d. Voided 30 mL frequently, 48. b. b. 2. Relax her abdominal muscles when she lifts an object This assumption is not appropriate, and the feelings and concerns of the client should be addressed. A skill for which the ap has received instruction the - Course Hero & 5. 1. 3. This would be an acceptable task to assign to the UAP. A client receiving heparin injections for deep vein thrombosis. 5. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. c. Request a tray without pork c. Raised toilet seats Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. b. Select all that apply A nurse is caring for a client who is immobile. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. A nurse is caring for a client who has a wound infection. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 1. Semi-formed stools are great news! There may be a good reason that the tray was not served. b. Hearing loss Transfer essential medical record to the receiving facility. e. Dysuria, 49. d. Proceed with the preparation of the patient's surgical procedure, 15. Estimate the number of Calories in two tablespoons of peanut d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. 3. 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. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. 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. a. I wish I didn't have to attach the electrodes to my skin However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. 1. 4. Client one day post kidney transplant. Which of the following items should the nurse include on the lunch tray? 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. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. 2. 4. 1. Client with ureterolithiasis who requires frequent PRN pain medication. (SATA) -Bathing a client who had an amputation 2 days ago. This service focuses on teaching the primary caregiver to meet the client's needs Incorrect: The client does need to have food; however, there is another action that should be performed first. 3. 1. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. Besides, a charge nurse is a leader on the floor and should possess . NUR 112 Practice Assessment Flashcards | Quizlet The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. 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. c. The client's culture c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day Which of the following findings indicates that the client is meeting this goal? 5. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. d. Message, 67. 2. Select all that apply d. They disclose more personal information, a. c. Physical therapist Which of the following actions should the nurse include in the plan? The surgeon initially prescribes a clear liquid diet. Which of the following actions should the nurse take? Narrative interaction A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. 4. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. b. Assess the client 2. 4. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. Showing disapproval Two nurses lifting the client under the shoulders 1. 1. Place the client in a lateral position 2. Which of the following interventions should the nurse include? Correct. Each state BON differs in that also some have treatment programs they administer themselves. 2. 4. Protective Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. In what order should the nurse assess assigned clients following shift report? Remember, pick the killer answer first! Which of the following should the nurse identify as an interpersonal variable? Ask the client to perform a return demonstration of insulin injection c. When asking the client how he completes his ADLs This is a diabetic clinic. c. Inflate the balloon when the urine flow stops 1. A lack of rapid eye movement (REM) sleep d. Bend at the knees when picking up an object, 99. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Focus on the client's present circumstances instead of his personal stories The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. 2. 3. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. 5. 2. This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. This action is a defensive intervention, and does not address the quarrelsome behavior. I'm drinking plenty of fluids." a. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. d. I shouldn't advice you about what is ultimately a personal decision, b. 4. d. Sleep apnea Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. The client can indicate desire for Do Not Resuscitate (DNR). Solved 4. A charge nurse is making client care assignments. | Chegg.com 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). Speak to the UAP first and then decide if a between meal supplement is needed. 4. Teaching about a medication The stem does not indicate any loss of neurological function resulting from the seizure activity. 4. 1. If a sentence is already correct, write CCC. 4. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. Initiate oxygen and IV lines as needed. The third client would be the one needing a dressing change. c. Explain the risks and benefits of the procedure 3. This protein is released by cells in the stomach. c. Review a low-sodium diet for the client who has hypertension A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Ask the charge nurse to evaluate the intervention. Client scheduled for breast reconstruction after mastectomy. A charge nurse is making client care assignments. Which tasks should the charge nurse delegate to the nursing assistant? 6. Remove all metal necklaces Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. leadership management of care nurse on unit is providing care for group of clients. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. What would the approximate meaning of photoelectric be, based on these root words? d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. d. Talk with the client's partner, b. What task would be best to assign to the LPN/LVN? Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Which of the following actions should the nurse take to assist the client with feeding? Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? Autonomy vs shame and doubt It's unfortunate that I have to be in the hospital for this treatment Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? d. Mask, 83. 1. A client on a surgical unit frequently quarrels with the staff. Photo comes from the Greek word for light. b. Irrigate the wound with an antiseptic prior to obtaining the specimen Feedback A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. 6. a. A nurse is caring for a client who is about to have a colonoscopy. d. What have you done in the past to cope with this issue? The best practice committee works to improve clinical practice based on current research. Patient safety must remain the priority. Provide a between meal supplement to the client. A nurse is planning care for a female client who has an indwelling urinary catheter.