c. I will cover the catheter so he cannot see it 4. 3. The charge nurse on the postpartum unit is making assignments. 1., 4., & 5. On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. Feedback An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. A nurse is caring for a client who is about to have a colonoscopy. This protein is released by cells in the stomach. Try different methods of oral care on unresponsive clients to see what works best. The option does not say the client is terminal, in a vegetative state, or in a coma. Invite staff to contribute ideas on scheduling changes. Which nurse should be assigned to care for this client? a. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. d. Sleep apnea 4. In which harmonic number n is the string vibrating? It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). Which of the following findings indicates that the client is meeting this goal? Places the soiled linen in the floor before bagging it Temporary urinary retention This is a diabetic clinic. Following a large hurricane, multiple clients arrive at the emergency room for treatment. Report the incident to the charge nurse 3. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. a. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. Both of these clients are terminal. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. c. Document in the client's medical record that she completed an incident report 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 client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. Providing hygiene care to a client who is HIV positive Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. 2. d. Ambulating the client in the hallway, c. Explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on affective learning), 80. 4. 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. The client with cystitis is stable and has a predictable outcome. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Charge nurses have integral roles in healthcare organizations. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Correct: Did you notice the hint? 1. a. a. Auscultate breath should at least ever 2 hr Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? d. Counting radial pulse, 100. Education Write N next to the nonessential clauses and E next to the essential clauses. 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. 1. d. Explain oral hygiene to a client receiving chemo A nurse instructs a female client about collecting a midstream urine sample. Incorrect: This group of clients needs specialized care. Which of the following methods should the nurse plan to use? 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). 4. 2. a. What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? 2. Which of the following interventions should the nurse include? The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. a. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. The LPN/LVN can reinforce teaching. a. A nurse who is 10 weeks pregnant. Sudden attacks of sleep Changing the subject Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. 5. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Who should the nurse see first? A client with COPD complaining of shortness of breath on exertion. Which of the following should the nurse identify as an interpersonal variable? Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Which of the following actions should the nurse perform when opening the sterile pack? 1., 2., 3., & 4. Select all that apply A nurse is caring for an older adult client who has a fractured hip and will require rehab care. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. There may be a good reason that the tray was not served. The cleint's family asks the nurse for info about this type of care. The nurse voices his concern to the charge nurse. 2. a. A nurse is caring for a client who has limited hand movement. The nurse should initiate a referral with which of the following members of the interprofessional health care team? The infusion rate has stopped but the tubing is not kinked Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Which of the following actions should the nurse take regarding informed consent? Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? 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. 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. The nurse prefers to check all vital signs on all clients. b. The nurse who made the medication error should take which of the following actions first? d. Water heater temp 54.4 C (130 F) 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. The report should contain consequences. A goal for this client is to use proper body mechanics at all times. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. and 16 g of fat. Draining the colostomy bag on a client with diarrhea. 2. a. Which of the following actions should the nurse take first? with this question, the nurse is using which of the following communication techniques? A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day Channel 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. c. Washes and rinses her hands for 10 seconds, 11. Report of feeling pressure Protective d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Correct: The client who has a cast and requires pain medication is a stable and predictable client. Which of the following actions should the nurse take? Client with cast to right leg requiring pain medication. 3. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 4. The charge nurse is developing patient care assignments for the evening shift and needs to assign clients to a licensed practical nurse/licensed vocational nurse (LPN/LVN) and a certified nursing assistant (CNA). Take several shallow breaths during the procedure The nurse is using which of the following therapeutic communication techniques? b. I should call my doctor if I find it harder to concentrate Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A lack of rapid eye movement (REM) sleep This is an appropriate prescription. Perform range of motion (ROM) exercises at least 2-3 times daily 2. The best practice committee utilizes current research in their recommendations. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 3. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1. 2. The client states, "I am so nervous about what the doctor might find during the test." a. Hypotension It's just not the right time for me to do this a. Clarification Place the client in low Fowler's position c. Rephrase statements the client does not hear Hold the penis at a 30 to 45 degree angle when inserting the catheter A nurse is adhering to standard precautions while caring for a group of clients. c. Gender c. When asking the client how he completes his ADLs 6. (Select all that apply.). Which client should the nurse assess first? b. I will begin once the client's discharge order is written b. Besides yourself, there are the following staff: Your unit has 12 beds. Dexlansoprazole 30 mg PO daily. b. c. Lock the medication in a room and finish preparing it after returning from the emergency The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. 3. a. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. 4. What options would be appropriate for the nurse to take? The client with chronic emphysema has expected shortness of breath. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. 2. In which situation should the nurse consult the client's advanced directive? 5. These are appropriate tasks for an UAP to complete. c. I'll need to shave the hair off the skin where I place the electrodes Which of the following client statements indicates an understanding of the procedure? Symbolic communication b. This situation is considered an external disaster which means the hospital will be expecting multiple victims. 1. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Request a prescription for a medication to ease the client's anxiety