Incorrect: The charge nurse does not have to assess every client. The client should be assessed first to rule out respiratory difficulty and hemorrhage. The nurse is focusing on which of the following elements of the communication process? b. Wash the area of the puncture thoroughly with soap and water Incorrect: This client is exhibiting early signs of increased intracranial pressure. What is the appropriate assignment? Perform range of motion (ROM) exercises at least 2-3 times daily The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. c. I will cover the catheter so he cannot see it c. Malpractice An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. Nothing will get passed the complete blockage. 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'll apply ankle to my ankle today and tomorrow d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. a. c. Hallucinations at the onset of sleep c. Holds the soiled linen against her body while carrying it to the linen bag The supervisor can only send one LPN/LVN to the floor. 1. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 4. 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. b. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. 1., 2., 3., & 4. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. c. Visual observation for nonverbal signs of pain Notify the primary healthcare provider. Provide an adaptive feeding device for the client, 50. 1. A nurse is assessing a client who is experiencing prostatic hypertrophy. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. b. Rewrite each incorrect sentence to correct the error. This referral would be appropriate. 1. An LPN/VN has been floated to the emergency room following a chemical plant explosion. When asking the client about his receptiveness to the transfer Which of the following client statements indicates an understanding of the procedure? Based on the information provided in report, which client condition should be the nurse's priority? b. I'll rewrap my ankle starting from the knee down Which client should the nurse see first? 5. Transfer essential medical record to the receiving facility. c. Behaving defensively c. Industry vs inferiority Client with ureterolithiasis who requires frequent PRN pain medication. The key word in the stem is first. a. Which of the following actions should the nurse take prior to administering the tube feeding? 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. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. 2. The reason for the UAP not feeding the client needs to be determined. 4. Assessing this client and titrating the diltiazem requires the skills of an RN. The nurse considers various ideas submitted by team members. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. The below statement corresponds to a numbered sentence in the passage. A client requesting assistance packing his belongings for discharge later today., Denial Ask client if they are eating small, frequent meals. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 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. This would be an acceptable task to assign to the UAP. d. Motor impairment, 84. Which of the following info should the nurse include? This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. a. There are a total of 10 adult clients. Involve the client in their plan of care. 1. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. c. Paraphrasing 2) Assist a client to ambulate using a gait belt. Which prescription should the nurse question and have corrected? 4. Client scheduled for breast reconstruction after mastectomy. A nurse is assessing a client who has narcolepsy. 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. Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. 1. Both of these clients are terminal. These are appropriate tasks for an UAP to complete. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. The nurse has been assigned four clients. All these clients have a GI problem. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. A high concentration of carbon monoxide can cause death What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? b. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. 1. a. This is a task that can be delegated to the LPN/LVN. Did you recognize ureterolithiasis as "kidney stones"? The RN with 8 years' experience in the Intensive Care Unit. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. A nurse asks a client how he is feeling. Select all that apply. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. Clients over the age of 65 must have a saline lock according to facility policy (Select all that apply.) Client scheduled for a dressing change to foot ulcer. 4. 3. 2. 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. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Assist the float nurse with the clients case. A nurse has just finished a wound irrigation for a client who requires contact precautions. c. Changing a dressing, 78. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. 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. b. a. Reposition the client every 3 hr d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) 1. a. b. with this question, the nurse is using which of the following communication techniques? 3. Most of the following sentences contain errors in the use of modifiers and comparisons. 2. The client attempted to climb over the side rails and fell 1) Bathe a client who had an amputation 2 days ago. A client receiving a blood transfusion that requires monitoring. a.) a. a. a. 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. Which of the following instructions should the nurse give to the client prior to the procedure? Which of the following interventions should the nurse include? Which client would be appropriate for the RN to assign to the LPN? c. Review the client's progress toward personal objectives Select all that apply INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. d. Determine if the client uses hearing aids, b. Incorrect: No, the monitoring is too specific for the med-surg nurse. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. 2. It is not a routine task. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. 4. 4. d. Sleep apnea The best practice committee works to improve clinical practice based on current research. Incorrect. Provide positive feedback to the UAP. 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. Select all that apply. c. Review a low-sodium diet for the client who has hypertension "The client is weak on the right side, so please assist the client with dressing . 1. c. I will begin upon the client's admission to the facility This is an appropriate and safe action for the unlicensed nursing assistant to do. Protective 1. 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. 3. 4. 1. Feed the client after warming the food. Removing the client's dentures The RN with 5 years' experience in the Labor and Delivery unit. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Incorrect: Moistening the dentures will ease insertion. What is the major histological difference between thick and thin skin? Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. A client on a surgical unit frequently quarrels with the staff. A two-hour limit on visits discourages quality time. The nurse is using which level of communication at this time? 1. Place the pack on a sterile work surface INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. A charge nurse is making client care assignments. This client will also need a lot of education regarding anti-rejection medications. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Warm the feeding solution to the body temperature 1. 2. Client with a T-5 spinal cord injury beginning rehabilitation therapy. Select all that apply. Discarding the first urine voided by the client starting a 24 hour urine test. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. Which of the following client statements should indicate to the nurse the need for additional teaching? So, the UAP can assist a client to brush and floss teeth. c. Can you tell me why you chose me? Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. The charge nurse knows what client would be most appropriate for this LPN? c. Measurement of residual urine after urination When determining if the client is eating a well-balanced diet a. a. Reach around the pack and open the top flap away from the body, 53. 3. Assign more daily tasks to the UAP. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. However, providing care for missing teeth would also be within the LPN scope of practice. e. The urge to move the legs when trying to sleep, 66. A client with exacerbation of COPD reporting dyspnea. Accept the client's behavior as confrontational. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. 2. Evaluate client's safety risk factors. Airborne Compartment syndrome could be developing which can impede circulation and cause nerve damage. Select all that apply 3. b. A charge nurse is making client care assignments. 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. A nurse is caring for a client whose partner asks to speak with the nurse. 3. b. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? Which of the following actions should the nurse take? A nurse is caring for a client who is scheduled for an elective surgical procedure. Focus on the client's present circumstances instead of his personal stories Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. a. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Incorrect: Informing is the same thing as teaching. The situation should be explored before bringing the supervisor in on the situation. The LPN can monitor the wound and provide care to the PEG insertion site. Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). b. Administering IV pain medication to a two day post op client. d. I shouldn't advice you about what is ultimately a personal decision, b. c. Blood-tinged urine Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. a. Bathtub with rails Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? & 4. 2. Write the letter of your choice on the answer line. a. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. The nurse has just completed a 12 hour shift. a. Hypotension 1. 3. 2. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. a. c. Distended bladder 1., 2., 3., & 4. Elderly client who fell and fractured the left femoral neck. 2. A lack of rapid eye movement (REM) sleep Allow the UAP to work without supervision. c. Initiate a liquid diet for the client 3. Correct: Hot water may damage dentures so intervention is needed. A client receiving heparin injections for deep vein thrombosis. Describe the types of machining operations that can be performed on a lathe. Elderly client admitted 30 minutes ago with reports of constipation for four days. Reach around the pack and open the top flap away from the body 2. a. A nurse is caring for a client who is postoperative following abdominal surgery. Symbolic communication b. A client with a fractured right humerus who reports the cast is too tight. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Which client should the nurse assess first? This service began with the client's admission to the hospital, 18. Make referrals to community services. 1. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. Removing the client's dentures The client must understand the need for restraints 1. 5. A nurse is caring for a client who is about to have a colonoscopy. & 6. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. d. Talk with the client's partner, b. A nurse is filling out an incident report after finding a client lying on the floor. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Nurses Report Sheet Template Nicu. b. 5. 3. Although this will require assessment, this client is not the priority at this time. b. 4. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? Respite care allows the primary caregiver time away from day-to-day care responsibilities A nurse is caring for a client in the orientation phase of the nurse-client relationship. 9. A nurse is caring for a client within the intimate zone of the client's personal space. Provide a between meal supplement to the client. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Review the action of insulin therapy Remember, pick the killer answer first! Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. 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. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. Did you think dehydration and fluid volume deficit? Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Select all that apply. 1. Moistening the dentures prior to inserting them When the licensed person cannot determine this, the task should not be delegated. (Select all that apply) Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen Which of the following should the nurse include as a criterion for applying restraints? A nurse asks a client to share personal stories. 4. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? b. I will keep the fluorescent ceiling light on in my room at night However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. Decide which choice fits best in the blank. This would be out of the UAP's scope of practice. Aplastic anemia is a rare but serious condition. 2. c. I will place an area rug at the entry of my bathroom Right forearm Each state BON differs in that also some have treatment programs they administer themselves. Which of the following physiological responses to prolonged immobility should the nurse expect? c. Decreased sodium excretion Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Which of the following items should the nurse offer the client? 5. This individual should be provided appropriate comments of appreciation for this accomplishment. c. Do not eat or drink anything the morning of the test When a family member asks how respite care can help, which of the following responses should the nurse provide? Select all that apply. A client who is disoriented and awaiting transfer to a long-term care facility. Notify clients that the disaster plan has been put into effect. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. c. Consensus evolves in this stage A person can be designated to make medical decision in the event the client cannot. Pain d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound For Option #3, you may have recognized MgSO4 as being magnesium sulfate. If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. Besides yourself, there are the following staff: Your unit has 12 beds. 2. 2. d. Reduced blood viscosity, a. Auscultating heart sounds Yes! The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. The nurse could definitely be part of the committee. b. 1. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? This protein is released by cells in the stomach. c. Raised toilet seats 2. Assigning blame for the changes to administration will not help staff adjust. Remind the client that a signed informed consent form is a legally binding document "Please explain what you mean by the word 'nervous'.". Correct: An LPN/LVN's scope of practice includes tasks such as wound care. a. Ask the charge nurse to evaluate the intervention. The nurse should not be assigned to provide care if impairment is suspected. d. I will begin once the client's insurance company approves discharge coverage, b. Tenderness over the symphysis pubis To remove gastric acid that might cause dyspepsia b. eminent A nurse is caring for a client who is immobile. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. c. Inflate the balloon when the urine flow stops 3. 5. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 2. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. The client is reporting anxiety, discomfort, and a feeling of bloating. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Collecting I & O totals for unit clients at the end of shift. Charge nurses have integral roles in healthcare organizations. Where on the body is each type of skin found? The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. The nurse is caring for four clients. 2. Which referral would most likely be appropriate for the nurse to make? Hearing loss c. The client's culture 2. 55. 4. Correct: The medical nurse can be assigned to this client. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Besides, a charge nurse is a leader on the floor and should possess . The surgeon initially prescribes a clear liquid diet. In what order should the nurse assess assigned clients following shift report?

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