In what order should the nurse see the clients? Remember airway, breathing and circulation (ABCs). Which of the following statements should the nurse make? 1. which client would be most appropriate to assign a licensed practical nurse (lpn)? 1. A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. Which of the following responses should the nurse make? Assigning blame for the changes to administration will not help staff adjust. 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). 3. 4. A cardiac step down unit has requested float staff because of multiple impending admissions. 2. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. c. Depression Which of the following tasks should the charge nurse reassign to a licensed nurse? 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. Which client can be assigned to the LPN? Teaching insulin self administration to a diabetic client. Which of the following tasks should the nurse delegate to AP? In what order should the emergency department triage nurse send these clients to a room for treatment? This would be out of the UAP's scope of practice. 1. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. b. Assigning tasks to an AP a. Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Which of the following actions is the nurse's priority? This is normal for clients with hemorrhoids. 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. This is an appropriate prescription. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. Suggest splitting the shift with another nurse. 3. The area surrounding the insertion site feels warm to the touch The nurse should call for immediate help so that a safe care environment is maintained for all clients. 1. 5. A nurse is caring for a client who is about to have a colonoscopy. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? 3. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. A nurse is prioritizing care for two clients at the start of the shift. 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. Documentation is a communication tool for the interprofessional health care team. a. b. I'll rewrap my ankle starting from the knee down Incorrect: It is out of the UAP's scope of practice to administer medication. 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. a. For which of the following actions should the nurse intervene? c. There is fluid leaking around the insertion site Select all that apply. Yes! d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 3. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. Also, making a surgical bed for the client returning from surgery is a basic procedure. Education The client can indicate desire for Do Not Resuscitate (DNR). 2. A nurse is caring for a client who has a mental health disorder. Which of the following should the nurse identify as an interpersonal variable? Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29. Identify and assess each incoming client. It can result in muscle spasm and tissue damage. Thoracentesis reporting shortness of breath. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Feed a client that had a stroke 3 months ago. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. The nurse is planning care for a client admitted with Alzheimer's Disease. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Therefore, this client would not be a priority over a client who may be experiencing a MI. Call the client's provider and 16 g of fat. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. c. Explain the risks and benefits of the procedure (Select all that apply.) The report should contain consequences. This stage is when testing occurs to identify boundaries of interpersonal behaviors A charge nurse is planning client activities for the day. What was the rationale for this plan? b. b. The assignment process requires constant evaluation and reevaluation of information and priorities. 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. This is an appropriate and safe action for the unlicensed nursing assistant to do. Document current functional status assessment 3. The nurse voices his concern to the charge nurse. They are more direct when discussing issues d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Initiative vs guilt Remind the client that a signed informed consent form is a legally binding document a. Announce the new changes at the monthly staff meeting. a. Broth The nurse should do this when repositioning is needed. Drag and Drop the items from one box to the other. A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. Airborne An adult (18 years or older) can create an advanced directive. Only the state Board of Nursing can legally determine the LPN's scope of practice. b. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Notify the board of nursing (BON) that the float nurse is an alcoholic. 2. Which of the following statements should the nurse make? Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Handoff and Nursing Report Sheet. 4. Which of the following actions is an example of a violation of confidentiality? This referral would be appropriate. Cardiac catheterization with a decreased pedal pulse below insertion site. c. Washes and rinses her hands for 10 seconds, 11. 2. The nurse is responsible for the assessment of all vital signs of post-op clients. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Perform catheterization when you recognize the urge to void The expected standard of care was strict bed rest), 96. b. Battery Which client would be appropriate for the RN to assign to the LPN? d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. A nurse is caring for a client who is immobile. 4. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. The client should be assessed first to rule out respiratory difficulty and hemorrhage. A nurse is caring for a client who has a hip fracture that requires surgical repair. To focus on effective learning with this client, which of the following interventions should the nurse use? c. Face shield When the licensed person cannot determine this, the task should not be delegated. Phone report to the receiving nurse. Incorrect. Decide which choice fits best in the blank. Explain oral hygiene to a client receiving chemotherapy The third client that should be sent back for treatment is the female client stating she has been raped. Accept assignment, documenting personal concerns regarding work conditions. e. Feed a client who had a stroke 3 months ago, 31. a. b. This is outside the scope of practice for the LPN/LVN. Which of the following statements should the nurse identify as an indication that the client requires further clarification? Start MgSO4 at 3g/hr IV The LPN should refuse the intervention. d. Identifying the client by name when making a referral for home health services, 30. Which of the following actions should the nurse take? "Please explain what you mean by the word 'nervous'.". a. b. A nurse who is on hormone replacement therapy. 4. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 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. 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). A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. A nurse has completed an informed consent form with a client. Asking for an explanation 4. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. This client could be transferred with traction still maintained. Which of the following physiological responses to prolonged immobility should the nurse expect? A nurse is preparing a sterile field. One nurse lifting as the client pushes with his feet The client with cystitis is stable and has a predictable outcome. (Select all that apply) d. Complete an incident report, 70. b. Hold the penis at a 30 to 45 degree angle when inserting the catheter
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