d. Remove and reinsert the NG tube, a. A nurse is caring for a client who expresses anxiety about his impending surgery. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? 1. Alert all off-duty personnel to stand by in case of call- in. A nurse is caring for an older client who is at risk for skin breakdown. *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. Elevating the head of the bed 30- 40 for the client post thoracotomy In which situation should the nurse consult the client's advanced directive? 3. A charge nurse is making client care assignments. 3. 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). Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. b. This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. 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). It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. Yes! c. I will make sure my visitors smoke outside d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. What is the best care assignment for this client? 2. Complete a client assignment sheet for the oncoming staff. Which prescription should the nurse question and have corrected? 4. A client with a fractured right humerus who reports the cast is too tight. The option does not say the client is terminal, in a vegetative state, or in a coma. Select all that apply b. Cardiac catheterization with a decreased pedal pulse below insertion site. 3. 2. b. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Incorrect: Informing is the same thing as teaching. & 3. 2. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. d. I have a set of my brothers' crutches in the basement I can also use, a. Which client can be assigned to the LPN? b. I will keep the fluorescent ceiling light on in my room at night 3. d. Transporting a cerebrospinal fluid specimen to the lab Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. 3. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. 1. c. Why are you crying? b. December 5, 2020. b. To confirm the placement of the NG tube Ask the charge nurse to evaluate the intervention. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Which of the following statements by the nurse would provide UAP with the best directions about an assignment? 2. 3. _________________ (magnanimous), a. generous d. What have you done in the past to cope with this issue? Each state BON differs in that also some have treatment programs they administer themselves. Incorrect: This group of clients needs specialized care. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. 3. d. Go to employee health services, b. A medical-surgical LPN has been sent to a short-staffed pediatric unit. A nurse is caring for a client who is scheduled for an elective surgical procedure. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. b. c. Hand-off technique 1. Removing the client's dentures A nurse who is on hormone replacement therapy. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. This client needs ongoing monitoring which is within the scope of practice for the LPN. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. Irrigate a client's ear canal. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? 4. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? c. Rephrase statements the client does not hear Show client who has conjunctivitis how to clean the eyes. 4. Client one day post kidney transplant. Ask the float nurse, "Have you been drinking?" 3. 1. b. The RN requests reassigning at least one of the clients to another nurse. Which of the following findings should the nurse expect? Select all that apply. b. Draining the colostomy bag on a client with diarrhea. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? 4., & 5. 4. a. Provide an adaptive feeding device for the client, 50. Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. c. Provide the client with a diet high in protein Which of the following tasks should the nurse delegate to AP? The nurse should not be assigned to provide care if impairment is suspected. Read all the current literature related to oral care on unresponsive clients. 4. c. Request a tray without pork with this question, the nurse is using which of the following communication techniques? d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound This situation is considered an external disaster which means the hospital will be expecting multiple victims. The infusion rate has stopped but the tubing is not kinked The client with cystitis is stable and has a predictable outcome. What options would be appropriate for the nurse to take? a. The nurse is using which level of communication at this time? Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 3. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Determining the client's length of stay It is within the LPNs scope of practice to administer antibiotics. A nurse is having difficulty caring for a client due to variables affecting the communication process. A nurse asks a client to share personal stories. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. a. I will wear gloves when removing food from the freezer Patient safety must remain the priority. 4. a. b. Donation costs are the responsibility of the donor's family and estate Select all that apply. The best practice committee utilizes current research in their recommendations. a. Client with ureterolithiasis who requires frequent PRN pain medication. Semi-formed stools are great news! Which nursing intervention should the charge nurse implement? a. Broth b. Assess the client Warm the feeding solution to the body temperature Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). 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. a. Shakes the soiled linen to remove any toilet paper remnants (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. Which of the following RNs should not be assigned to this baby? Which of the following actions should the nurse take? Which of the following client statements indicates an understanding of the procedure? Include any relevant statements the client made about the ulcer Which task would be appropriate for the nurse to assign to an LPN/VN? This client will also need a lot of education regarding anti-rejection medications. 1. Protective The best practice committee works to improve clinical practice based on current research. 6. a. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. 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. Once the client is stable, the UAP could perform this task. b. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. c. Washes and rinses her hands for 10 seconds Speak to the UAP first and then decide if a between meal supplement is needed. This is an elderly client who is a new admit. 1., 2., & 5. Confrontation should occur in the presence of a charge nurse or supervisor. Correct. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. 4. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Fruity breath. The nurse is planning care for a client admitted with Alzheimer's Disease. a. Clarifying A nurse is orienting a new assistive personal (AP) to the unit. 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). A nurse is caring for a client in the orientation phase of the nurse-client relationship. 2. b. A nurse is implementing direct nursing care for a group of clients in an acute care facility. We do not know the extent of her injuries based on what the option tells us. a. I wish I didn't have to attach the electrodes to my skin A two-hour limit on visits discourages quality time. Gathering needed equipment and supplies is within the scope of duties for the UAP. Discuss the assignment with another LPN. 3. Comatose client with end stage chronic obstructive pulmonary disease. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. d. Respite care is a continuation of psychological support after a family member dies. 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. b. 1. 4. a. 1. Assist the float nurse with the clients case. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. The nurse is responsible for the assessment of all vital signs of post-op clients. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. Provide an adaptive feeding device for the client For which of the following tasks should the nurse wear protective eye equipment. d. Sleep apnea 1. The nurse could definitely be part of the committee. This could indicate a worsening of this client's condition. A client has been admitted with folic acid deficiency anemia. Gather and apply dressings to open wounds. 4. 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. a. I will begin 48 hr before the client's discharge Which of the following actions should the nurse perform when opening the sterile pack? What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? butter, which contain 16 g of protein, 7 g of carbohydrates, Accept assignment, documenting personal concerns regarding work conditions. A nurse just back from maternity leave. Turn on local news for up-to-date information on the train derailment. Although this will require assessment, this client is not the priority at this time. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. The spouse can rescind the Advance Directive if the client becomes unresponsive. a. A cardiac step down unit has requested float staff because of multiple impending admissions. Which of the following statements should the nurse identify as an indication that the client requires further clarification? Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. 1. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. d. Perception Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. Which of the following indications should the nurse include? The stem does not indicate any loss of neurological function resulting from the seizure activity. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? d. Custard Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. The client with chronic emphysema has expected shortness of breath. 2. 2. 1. This service began with the client's admission to the hospital, 18. The client is getting better. Dentures should be stored in a denture cup. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. Which task should the nurse take responsibility for completing? A nurse is caring for a client who frequently attempts to remove his IV catheter. a. 2. Teaching insulin self administration to a diabetic client. Review a low-sodium diet for a client who has hypertension. Changing a colostomy bag. a. Monitor for GI upset 30 minutes after meals. The expected standard of care was strict bed rest), 96. 55. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? They are able to manage tasks related to basic care. d. Voided 30 mL frequently, 48. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. d. Counting radial pulse The client asks about his medications and their effects. A client diagnosed with rheumatoid arthritis needing discharge teaching. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. The nurse is reviewing some clients' prescriptions. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 10. 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 findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? Underline the adjective clause in each sentence. c. Do not eat or drink anything the morning of the test Correct. 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. 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. 4. 1., 2., 3., & 4. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? Identify and assess each incoming client. Call the family of a client suffering from dementia to discuss long term care placement. c. Consensus evolves in this stage 1. Each ROM movement should be repeated 5 times during the session. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. 3. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 2. A nurse is discussing the norming stage of the group development process with a student nurse. Removing the client's dentures Which of the following statements should the preceptor make? Which clients should be assigned to the CNA? Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Left upper forearm 1., 4., & 5. A nurse is preparing to obtain a blood specimen from a client by venipuncture. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. Encourage the client to be more cooperative. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. c. Initiate a liquid diet for the client 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. 1. A. 1. The primary healthcare provider may have suggestions but this is not the best first action. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. Place in priority order. Correct: Hot water may damage dentures so intervention is needed. When staff do not feel vested in any new process, there is a sense of underappreciation. Which of the following should the nurse include as a criterion for applying restraints? The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. A nurse is prioritizing care for two clients at the start of the shift. b. 2. 1. A nurse is teaching a client about carbon monoxide poisoning. 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. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 2. Nothing life threatening, but an assessment needs to be made regarding the ulcer. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. Autonomy vs shame and doubt However, there are some basic points which are standard among all facilities. 1. 2. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Decide which choice fits best in the blank. 2. Incorrect: This is not completely practical for everyone. Charge nurses have integral roles in healthcare organizations. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen Phone report to the receiving nurse. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. The charge nurse on the postpartum unit is making assignments. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? b. No! Obtain a bedside commode for the client's use The nurse cannot assign assessment and evaluation of the nursing process to the UAP. A charge nurse is making assignments for an oncoming shift. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. a. The surgeon initially prescribes a clear liquid diet. A charge nurse is making client care assignments. 3. 3. Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 1. A client requesting assistance packing his belongings for discharge later today., 2. Client who is a diabetic experiencing diabetic neuropathy. Incorrect: The nurse is responsible for evaluating a client. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. The client says, "go away, no one can help me." 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. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. What action should the nurse implement first to ensure client safety? a. 4. Place in priority order. c. Explore the client's feelings about dietary modifications This client could be transferred with traction still maintained. A client requesting assistance packing his belongings for discharge later today.. When a family member asks how respite care can help, which of the following responses should the nurse provide? A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department).