For Option #3, you may have recognized MgSO4 as being magnesium sulfate. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage The nurse caring for the client at the time of death requests organ donation 1. Which of the following actions indicates that the AP understands the principles of infection control? The cause of the fall may be cardiac, but the question does not indicate this. a. The nurse should perform which of the following activities in this space? Aplastic anemia is a rare but serious condition. Injuries from a motor-vehicle accident can be life threatening. 3. Asking for an explanation 5. An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension. Refuse the overtime assignment, being prepared for disciplinary action. Measure urine output when client voids. c. Distended bladder Monitor for behavioral changes. Correct: An LPN should be assigned clients with predictable outcomes. b. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain Reach around the pack and open the top flap away from the body, 53. Which of the following tasks should the charge nurse reassign to a licensed nurse? Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). Incorrect: The nurse retains the responsibility for the delegated task. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Remind the client to avoid tight fitting clothes. Correct: The client may be experiencing a myocardial infarction and requires further assessment. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. A client on a surgical unit frequently quarrels with the staff. is a new graduate in orientation. Which of the following info should the nurse include? 1. Comatose client with end stage chronic obstructive pulmonary disease. Although this will require assessment, this client is not the priority at this time. e. The urge to move the legs when trying to sleep, 66. Furosemide 40 mg PO q.d. Which of the following statements should the nurse identify as an indication that the client needs further teaching? During exacerbation, the client will have many diarrhea stools. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Which of the following pieces of PPE should the nurse remove first? b. Urinary frequency for several days Which of the following actions should this nurse take? Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. The facility has insurance that will cover malpractice litigation A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Client diagnosed with Guillain-Barre' who is receiving ventilator support. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Which of the following client statements indicates an understanding of the procedure? 1. Which client would be appropriate for the RN to assign to the LPN? Which client should the nurse assess first? 4. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Decreased RBC production a. 1. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. 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. A list of current medications is sent to the facility. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Based on this information,what should the nurse do? d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. b. c. Notifying the provider of physical exam findings 2. 1., 2., 3., & 4. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Offer to take one of the clients. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? Education This client could be transferred with traction still maintained. Incorrect: The concern here is the client being fed their meal. Remove all metal necklaces The client must understand the need for restraints Moistening the dentures prior to inserting them The spouse can rescind the Advance Directive if the client becomes unresponsive. Checking capillary refill beneath the client's fingernail Place in priority order. 1. Initiate oxygen and IV lines as needed. 1. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 1. b. Provide positive feedback to the UAP. 4. This referral would be appropriate. 4. a. Nothing by mouth (NPO). 4. This client needs ongoing monitoring which is within the scope of practice for the LPN. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. The RN with 10 years' experience pulled from the ER. 3. a. Reposition the client every 3 hr Narrative interaction Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 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. 5. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. Handoff and Nursing Report Sheet. 3. a. Clarifying b. Negligence e. Dysuria, 49. Announce the new changes at the monthly staff meeting. This protein is released by cells in the stomach. Delegate 2 nurses to work with the client. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Places the soiled linen in the floor before bagging it Assessing this client and titrating the diltiazem requires the skills of an RN. a. 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. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. This service began with the client's admission to the hospital Select all that apply. 2) Assist a client to ambulate using a gait belt. (Select all that apply.) 1. Write N next to the nonessential clauses and E next to the essential clauses. Which of the following interventions should the nurse include? 4. a. c. Explain the risks and benefits of the procedure Incorrect: The nurse cannot assign teaching to the UAP. c. I'll clean the inside of the container with a wipe A nurse is assessing a client who is experiencing prostatic hypertrophy. Correct: Did you notice the hint? a. Which clients should be assigned to the CNA? As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. Client scheduled for a dressing change to foot ulcer. 2. Select all that apply Triage and assign color-coded tags to each client. 208 4. Which of the following nontherapeutic communication techniques is the nurse using? a. 1. Charge nurses have integral roles in healthcare organizations. 5. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. 3. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. d. Move to the opposite side of the pack and open the fourth flap, 54. 3. Place the pack on a sterile work surface 4. 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. Which of the following actions should the nurse take? A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Drag and Drop the items from one box to the other. 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. 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. Select all that apply. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Client with a T-5 spinal cord injury beginning rehabilitation therapy. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. (Select all that apply.) The best practice committee works to improve clinical practice based on current research. b. The first vital sign check was performed by the nurse. 2. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). c. Open the right flap with the left hand Currently, your census is 11, with one empty bed. A post-cardiac catheterization needing assistance with bedpan. Complete blockage of the large intestine. c. Discard the tablet and obtain another dose of medication Report the incident to the charge nurse a. 2. d. I decline this opportunity at this time, b. Provides day to day direction and supervision to assigned direct patient care staff. 4. 5. 1. Assist a client to ambulate using a gait belt. 4. d. Establishing the client's secondary medical diagnoses, b. Prepare a list of clients who could quickly be discharged or transferred. c. Notify the nurse manager Talk to each nurse about concerns related to assigned clients. b. 3. 3. This determination is needed to assure client safety is being considered. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Client to receive dietary education. A client with COPD complaining of shortness of breath on exertion. Which of the following actions should the nurse take? 4. 3. Cardiac catheterization with a decreased pedal pulse below insertion site. Which of the following actions should the nurse take first? Gather and apply dressings to open wounds. Reach around the pack and open the top flap away from the body This can prevent harm to client's. Lumbar puncture reporting a headache. The infusion rate has stopped but the tubing is not kinked Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. Which of the following actions should the nurse take? Place the client in low Fowler's position The client then states, "I have changed my mind and do not want to have the procedure done." 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. What was the hint? Could you try contacting a support group a. Describe the types of machining operations that can be performed on a lathe. 1. Based on these findings, to which of the following providers should the nurse request a referral for the client? b. b. 2. d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. A nurse is caring for a client who is postoperative. a.) Which of the following statements should the nurse identify as an indication that the client understands the instructions? For which of the following tasks should the nurse wear protective eye equipment. The nurse received a client following surgery 8 hours ago. Correct: The client has the right to be involved in the decision making of their care. Elderly client who fell and fractured the left femoral neck. In order to reorganize staffing, the nurse manager should initiate which action first? c. Inflate the balloon when the urine flow stops 3. Bargaining - Assisting a client to ambulate using a gait belt. *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. c. Assist the client to the floor and begin mouth-to-mouth There will likely be both physical and emotional injury that needs attention, which places this client third. The body needs vitamin B12 to make red blood cells. There is a possibility that a hypothermia blanket may be prescribed. b. I should call my doctor if I find it harder to concentrate The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. 4. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. c. Malpractice 4. Decreased or suppressed respiration are priority. b. So, the UAP can assist a client to brush and floss teeth. Serve milk products separately from meals c. Do not eat or drink anything the morning of the test Administering 3 g/hr IV of morphine would be extremely dangerous. Which region of the tRNA pairs with mRNA? This is an appropriate prescription. a. 1., 2., 4., & 5. Relief of urinary retention What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 3. Temporary urinary retention 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. e. an open perineal wound, 92. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. 5. An adult (18 years or older) can create an advanced directive. 212 Removing the abdominal dressing Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. b. A charge nurse is making assignments for an oncoming shift. c. Document in the client's medical record that she completed an incident report 1. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. 1. d. Complete an incident report, 70. Airborne What is the most appropriate action by the charge nurse? d. Routine acquisition of a urine specimen The client says, "go away, no one can help me." If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. d. I will begin once the client's insurance company approves discharge coverage, b. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. 4. 1., 3, & 4. 5. c. I suggest you talk with a mental health counselor about your concerns 3. b. Wash the area of the puncture thoroughly with soap and water a. a. I will keep my walker at the end of my bed 3. Denial a. d. Bend at the knees when picking up an object, 99. 2. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. c. Industry vs inferiority _________________ (magnanimous), a. generous c. I will cover the catheter so he cannot see it Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. Explain oral hygiene to a client receiving chemotherapy 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. A client receiving heparin injections for deep vein thrombosis. Performing passive range of motion (ROM) on the client with right sided paralysis. A nurse is admitting a client who has a partial hearing loss. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. 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. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. B. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee.