In what order should the emergency department triage nurse send these clients to a room for treatment? Therefore, this would not be the most appropriate nurse to assign to this client. Describe the types of machining operations that can be performed on a lathe. 1. Incorrect: The client does need to have food; however, there is another action that should be performed first. Client one day post kidney transplant. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. 3. c. Nonfat milk Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. a. Gloves Which region of the tRNA pairs with mRNA? Of my three brothers and sisters, my sister Giselle has the best sense of humor. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) 2. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 4. 3. 1. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. Have a pen and paper handy 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. A client receiving heparin injections for deep vein thrombosis. A nurse is caring for a client who is postoperative. Semi-formed stools are great news! It is not a routine task. Which of the following statements should the nurse identify as an indication that the client requires further clarification? a. I will keep my walker at the end of my bed When asking the client about his receptiveness to the transfer If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. The RN with 8 years' experience in the Intensive Care Unit. 3. Sudden attacks of sleep Which of the following is the priority action by the nurse? The unit is short one staff member and will receive a nurse from the medical surgical unit. A nurse is teaching a client about the physical effects of chemotherapy. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a The nurse should initiate a referral with which of the following members of the interprofessional health care team? a.) Place the client in a lateral position a. A nurse is caring for a client who frequently attempts to remove his IV catheter. c. To determine the client's electrolyte balance a. (Select all that apply.). a. 1., 4., & 5. Administering 3 g/hr IV of morphine would be extremely dangerous. d. Assault, b. This stage is when testing occurs to identify boundaries of interpersonal behaviors Identify and assess each incoming client. c. Paraphrasing The nurse considers various ideas submitted by team members. 2. This would be an acceptable task to assign to the UAP. Select all that apply Which of the following actions should the nurse take first? a. I'll sit with my knees lower than my hips 5. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Correct: Traction should never be relieved without a primary healthcare provider's prescription. Which of the following infection-control precautions should the nurse use caring for this client? Document current functional status assessment PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. a. e. Talking with the client's partner, 79. 212 2. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. 2., 3. The nurse is focusing on which of the following elements of the communication process? c. I will inspect my crutches everyday for signs of wear Pain 1. Which of the following instructions should the nurse include? d. Droplet, d. Bend at the knees when picking up an object, 98. Which of the following types of communication breakdown does this response represent? Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? The supervisor can only send one LPN/LVN to the floor. 3. 4. 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. Vital sign measurement 4. b. d. Let's wait until tonight to see if he continues his behavior, 63. What action should the nurse take after mistakenly administering the wrong medication? A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Which of the following items should the nurse include on the lunch tray? Which of the following findings associated with urinary retention should the nurse expect? 1. b. This is not a situation that requires the LPN to notify the primary healthcare provider. The charge nurse must triage and assign clients to appropriate staff. (Select all that apply.) Which clients should be assigned to the CNA? Call the family of a client suffering from dementia to discuss long term care placement. 5. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. c. Review the client's progress toward personal objectives b. eminent If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. The nurse should perform which of the following activities in this space? Incorrect: This would unnecessarily alarm the clients. a. d. Discard the prepared medications and begin again after returning, d. I will wear synthetic clothing and woolen socks when using my oxygen (woolen and synthetic materials can generate static electricity and oxygen is a flammable gas - the client should wear cotton), 73. This client should report an improved respiratory, not shortness of breath. Place in priority order. 3. a. 3. 3. 2. A nurse is caring for a client who states, "I have got to get out of this hospital! This situation is considered an external disaster which means the hospital will be expecting multiple victims. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. 2. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Try different methods of oral care on unresponsive clients to see what works best. Soaking the dentures in hot water Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. b. A nurse is caring for a client who has emphysema and has difficulty with mobility. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Correct: If suspicious behavior occurs, it is important to keep careful, objective records. - Assisting a client to ambulate using a gait belt. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 1. What should the nurse do first? Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Select all that apply 1., 2., 3., & 4. Select all that apply Which of the following findings should the nurse expect? a. 1. What interventions can the nurse delegate to the LPN/VN? Use double bagging to remove soiled linen from the client's room Notify the board of nursing (BON) that the float nurse is an alcoholic. b. Handoff and Nursing Report Sheet. A client with a fractured right humerus who reports the cast is too tight. 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. 3. 4. 3. What is the most appropriate action by the charge nurse? For which of the following tasks should the nurse wear protective eye equipment. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? *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. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. c. Holds the soiled linen against her body while carrying it to the linen bag c. Interpersonal (interpersonal communication is face-to-face interaction with another person. 4. 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. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Ask the RN why the assignment is too heavy. Select all that apply. This includes medication enemas. c. Hand-off technique b. 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). 2. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. This is likely cholelithiasis, which will need to be checked out. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Delegate 2 nurses to work with the client. 4. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. a. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? 3. To which of the following rooms should the nurse assign the client? 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 who is 10 weeks pregnant. a. Pick up the tray and tell the UAP that they didn't do a good job. Airborne Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. Which of the following statements should the nurse identify as an indication that the client needs further instruction? 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. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. 3. Sudden attacks of sleep Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. b. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Select all that apply 3. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 2. b. The RN with 5 years' experience in the Labor and Delivery unit. 6. Client who is a diabetic experiencing diabetic neuropathy. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? a. Bathe a client who had an amputation 2 days ago Client scheduled for a dressing change to foot ulcer. Obtain a urine specimen from a client with an indwelling Foley catheter. 4. A nurse is caring for a client who has a hip fracture that requires surgical repair. a. 3. a. 1. b. I can detect the presence of carbon monoxide by a metallic odor The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. d. Custard Encourage client to express grief related to loss of independence. Incorrect: What seems to be going on with this client? 9. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Following the teaching, the nurse asks the client to describe one physical effect. What is the appropriate assignment? 3. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. This client needs careful monitoring and specialized care. The client is apparently stable and does not require any advanced assessment skills or specialized care. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. 1. Which of the following activities should the nurse perform in this zone? It's unfortunate that I have to be in the hospital for this treatment c. Changing a dressing, 78. c. Offer the client personal thoughts and beliefs The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). 1., 4., & 5. Only the state Board of Nursing can legally determine the LPN's scope of practice. Receive report from the emergency department (ED) on a new client. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound 5. To confirm the placement of the NG tube The charge nurse's best response is to first obtain the needed information to make the best decision. Besides yourself, there are the following staff: Your unit has 12 beds. Which preoperative prescription should the nurse question? Administer sodium polystyrene sulfonate enema. Gather and apply dressings to open wounds. In which harmonic number n is the string vibrating? Tenderness over the symphysis pubis A nurse is caring for a client who is postoperative following an appendectomy. 1., 2., & 5. b. b. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. c. Take the client to the bathroom every 2 hr Offer to take one of the clients. 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. Estimate the number of Calories in two tablespoons of peanut Draining the colostomy bag on a client with diarrhea. 1. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. a. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. 1. A post-cardiac catheterization needing assistance with bedpan. Confrontation should occur in the presence of a charge nurse or supervisor. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. d. Bend at the knees when picking up an object, 99. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 1. c. Use intermittent eye contact Place the client in low Fowler's position Remind the client that a signed informed consent form is a legally binding document d. Left forearm, b. Which of the following statements should the nurse make? c. Washes and rinses her hands for 10 seconds Review a low-sodium diet for a client with hypertension. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 3. Which of the following responses should the nurse make? Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? a. Everyone knows there are others who can chair this committee better than me Select all that apply. a. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 2. Incorrect: The nurse cannot assign teaching to the UAP. 3. d. Reduced blood viscosity, a. Auscultating heart sounds A charge nurse is making client care assignments. Monitor for GI upset 30 minutes after meals. Providing a passive response The key word in the stem is first. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Obtain a client's consent Checking capillary refill beneath the client's fingernail Alcoholic Anonymous 2. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A nurse enters an older adult client's room to insert a saline lock. This stage involves constructive efforts on the part of the group members Normally, red blood cells are flexible and round, moving easily through blood vessels. 4. 4. A charge nurse is making client care assignments. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. 3. 1. & 6. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. The client is considered unstable until assessed by the nurse. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Which of the following info should the nurse include? Discuss the competency of the surgeon The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). A charge nurse is making assignments for an oncoming shift. This service focuses on teaching the primary caregiver to meet the client's needs Twist at the waist when she moves an object to one side This service began with the client's admission to the hospital Did you recognize ureterolithiasis as "kidney stones"? A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. b. I'm so sorry to hear about this Who should the nurse see first? Observe the client before taking further actions d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. 2. Select all that apply c. Palpating for pedal edema Nurses Report Sheet Template Nicu. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. So, the UAP can assist a client to brush and floss teeth. The client was lying on the floor next to his bed c. Document in the client's medical record that she completed an incident report Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. 3. This is a task that can be delegated to the LPN/LVN. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. The body needs vitamin B12 to make red blood cells. 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. c. imaginary 2. Triage and assign color-coded tags to each client. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. d. Mask, 83. Which task would be appropriate for the nurse to assign to an LPN/VN? Each ROM movement should be repeated 5 times during the session. Select all that apply Administer tap water enemas until clear at 6 AM. The RN with 2 weeks' experience on the postpartum unit. 1., 3, & 4. a. A nurse is orienting a new assistive personal (AP) to the unit. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. I'm drinking plenty of fluids." Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. I am feeling much better since my discharge from the hospital and I think my kidneys are working again."