Briefly assess every client. Decreased RBC production Which of the following findings indicates that the client is meeting this goal? 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. b. 1. Feedback Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. 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. 1., 2., 3., & 4. Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. 3. Denial Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. 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. 4. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. 1. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Which nurse should be assigned to care for this client? This is the most stable of the four clients which places this client last to be seen. Notify the surgeon that the client wishes to withdraw informed consent for the procedure 3. A nurse is caring for a client who has a hip fracture that requires surgical repair. 4. 2. 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. I should call my doctor if I find it harder to concentrate Assist a client to ambulate using a gait belt The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 5. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. The reason for the UAP not feeding the client needs to be determined. c. Open the right flap with the left hand 2. Incorrect: This response overlooks a potentially severe problem. d. Discussing intake and output Explain to the RN that all the nurses have the same number of clients. 2. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. The nurse received a client following surgery 8 hours ago. a. 1. b. 2. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. 3. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. Which of the following instructions should the nurse give to the client prior to the procedure? Refuse the delegated intervention. Electric cords behind the furnitrure Client scheduled for a dressing change to foot ulcer. Collecting I & O totals for unit clients at the end of shift. 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. Triage and assign color-coded tags to each client. The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. 2. Decide which choice fits best in the blank. 2. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. An adult (18 years or older) can create an advanced directive. a. Gather supplies to prepare room for isolation. 3. The nurse would then start the 24 hour urine once the 1st void has been discarded. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. Provide an adaptive feeding device for the client Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Decreased or suppressed respiration are priority. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. a. A client requesting assistance packing his belongings for discharge later today., The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which clients would be appropriate assignments for the LPN/LVN? In what order should the nurse see the clients? 5. Which of the following explanations should the nurse provide? 4. Involve the client in their plan of care. A client receiving heparin injections for deep vein thrombosis. Performing passive range of motion (ROM) on the client with right sided paralysis. d. Highly concentrated urine, 91. The infusion rate has stopped but the tubing is not kinked 208 Hearing loss 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. 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? 3. 2., 3. Review the action of insulin therapy The stem does not indicate any loss of neurological function resulting from the seizure activity. (Select all that apply.) 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). This would be out of the UAP's scope of practice. Which of the following findings should the nurse expect? Which of the following statements should the nurse identify as an indication that the client needs further instruction? Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. This client can wait until the others are treated. c. I will inspect my crutches everyday for signs of wear A nurse is caring for a client who is immobile. 3. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? 1. Accept the client's behavior as confrontational. 3. 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. Relax her abdominal muscles when she lifts an object 1. a. Discarding the first urine voided by the client starting a 24 hour urine test. A nurse has completed an informed consent form with a client. Photo comes from the Greek word for light. c. Review the client's progress toward personal objectives Evaluate client's safety risk factors. Elderly client admitted 30 minutes ago with reports of constipation for four days. Suggest splitting the shift with another nurse. The client says, "go away, no one can help me." Aplastic Anemia Support Group. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. Place in priority order. a. d. Do you think crying will help? A nurse who is on hormone replacement therapy. 3. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The last client would be the one needing dietary education. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. b. 5. 4. 3. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. b. 1. 1. d. Identifying the client by name when making a referral for home health services, 30. c. Malpractice Select all that apply A client with epilepsy reporting an odd smell in the room. Correct. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. 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. Select all that apply Select all that apply. a. A client on a surgical unit frequently quarrels with the staff. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. Incorrect. 4. a. 2. Which of the following statements should the preceptor make? Which of the following actions should the nurse include in the plan? The nurse who made the medication error should take which of the following actions first? This stage involves constructive efforts on the part of the group members A client diagnosed with rheumatoid arthritis needing discharge teaching. Gathering needed equipment and supplies is within the scope of duties for the UAP. 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. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 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). Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. 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. The nurse should not be assigned to provide care if impairment is suspected. Ask the charge nurse to evaluate the intervention. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. Which of the following statements should the nurse identify as an indication that the client understands the instructions? Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. c. Offer the client personal thoughts and beliefs Allow families unlimited visitation around the clock to meet their schedules. 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 receives a client care assignment from the charge nurse that he believes is unfair. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a (Select all that apply.) Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Well, do you see the q.d.? 3. Remind the client that a signed informed consent form is a legally binding document Education a. d. Lean back in the chair, b. 4. d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. 3. A nurse is caring for a client who has a wound infection. Use adult diapers to prevent frequent clothing changes This client could be transferred with traction still maintained. Select all that apply 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. Where on the body is each type of skin found? 1. b. a. I will wear gloves when removing food from the freezer 2. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? A nurse is completing discharge teaching with a client. 2. e. Feed a client who had a stroke 3 months ago, 32. a. The client states, "I'm feeling a bit nervous today." c. Hallucinations at the onset of sleep It is quicker to administer medications intravenously in the hospital b. 2. 5. Correct: The client has the right to be involved in the decision making of their care. Incorrect: Moistening the dentures will ease insertion. 1., 4., & 5. Plan all care to be completed in early morning to allow afternoon for visitation. A client with fibromyalgia reporting generalized pain of 7 out of 10. 2. 3. Client prescribed antibiotics for cystitis. 212 In what order should the nurse assess assigned clients following shift report? *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. Providing hygiene care to a client who is HIV positive The charge nurse's best response is to first obtain the needed information to make the best decision. a. b. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. Dr. Frankenstein had seen himself as a(n) ?\underline{? A. To focus on effective learning with this client, which of the following interventions should the nurse use? (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 This assumption is not appropriate, and the feelings and concerns of the client should be addressed. The LPN should refuse the intervention. c. 214 A client with COPD complaining of shortness of breath on exertion. 3. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. 1. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. The nurse did not trust the new UAP. Respite care provides holistic support and care for a client who is terminally ill e. The urge to move the legs when trying to sleep, 66. Answer the following question to test your understanding of the preceding section: Which of the following responses should the nurse make? Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. 1. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. 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. 7. the nurse responds, "don't worry, no one will harm your family." 4. 1., 2., & 5. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. This is a task that can be delegated to the LPN/LVN. A nurse is engaging in relationship counseling with a male client. 4. Assist a client to ambulate using a gait belt Encourage the client to use self-exploration Disconnect client's nasogastric (NG) tube suction to allow ambulation. Vital sign measurement If you give the magnesium citrate, which is a laxative, what will happen? Perform the Heimlich maneuver This action is a defensive intervention, and does not address the quarrelsome behavior. When asking the client about his receptiveness to the transfer Drag and Drop the items from one box to the other. 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. Notify the charge nurse of the observations. The nurse suggest that the family might need to respite care services. d. Place the tablet directly into a medication cup, 36. Select all that apply 2. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. 3. A nurse is having difficulty caring for a client due to variables affecting the communication process. The facility has insurance that will cover malpractice litigation Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. 2. a. Broth Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. Nursing questions and answers. Select all that apply This would be an acceptable task to assign to the UAP. A nurse is preparing medication for a client when another client has an emergency. Use double bagging to remove soiled linen from the client's room So, the UAP can assist a client to brush and floss teeth. 1. 1. Yes! Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? 77. b. The nurse is reviewing some clients' prescriptions. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Charge nurses have integral roles in healthcare organizations. 3. b. Incorrect: The nurse retains the responsibility for the delegated task. A nurse is preparing to obtain a blood specimen from a client by venipuncture. & 4. Teach caregivers memory enhancement aids. 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). 4. Stand directly in front of the client c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). The charge nurse is making client assignments for a neuro-medical floor. Client diagnosed with inoperative brain tumor who is confused. 3. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. C-section planning discharge, postpartum infection, mastectomy. Channel 5. c. Washes and rinses her hands for 10 seconds, 11. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. Could you try contacting a support group Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) 4. Remove all metal necklaces b. 1. b. Assigning tasks to an AP Symbolic communication D. The nurse should assess the client for which of the following expected outcomes after catheter removal? a. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. 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. (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 1. Most of the following sentences contain errors in the use of modifiers and comparisons. 3. a. Auscultating heart sounds Based on these findings, to which of the following providers should the nurse request a referral for the client? b. which client would be an appropriate care assignment for this lpn? 1. "Please explain what you mean by the word 'nervous'.". 4. b. A nurse who is breastfeeding her 4 month old. Everything will be okay 2. 2. c. Paraphrasing Because the charge nurse observes and weighs . Client with cast to right leg requiring pain medication. Notify the board of nursing (BON) that the float nurse is an alcoholic. 3. 1., 2., 3., & 4. Explore the client's feelings 1. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take to assist the client with feeding? a. As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. 4. Complete blockage of the large intestine. a. I'll sit with my knees lower than my hips Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria.
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