The RN with 10 years' experience pulled from the ER. 5. A. d. Reflection, c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation), 37. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Who should the nurse see first? The assignment process requires constant evaluation and reevaluation of information and priorities. b. The client with cystitis is stable and has a predictable outcome. An adult (18 years or older) can create an advanced directive. Teaching about a medication 2. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. Did you recognize ureterolithiasis as "kidney stones"? a. Bathtub with rails The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. It's just not the right time for me to do this 2. The area surrounding the insertion site feels warm to the touch Nothing life threatening, but an assessment needs to be made regarding the ulcer. 2. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. c. Open the right flap with the left hand A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. The client's self-report of pain severity, 88. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Elizabeth Young BSN, RN-OCN - Registered Nurse - PIEDMONT CANCER A nurse is caring for a client who frequently attempts to remove his IV catheter. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. a. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. A nurse is planning to discharge a client who has quadriplegia to his home. Discarding the first urine voided by the client starting a 24 hour urine test. Serve food that have a hot/cold balance 3. M2.4 Making Client Care Assignments - GECC.pdf - Course Hero A charge nurse on an acute care unit is planning care for a client a. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. Which of the following actions should the nurse take? What is the major histological difference between thick and thin skin? Teaching insulin self administration to a diabetic client. Which of the following infection-control precautions should the nurse use caring for this client? Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. 5. Remember, pick the killer answer first! The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. b. A nurse is caring for a client who has a mental health disorder. 77. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. The nurse is using which level of communication at this time? Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. Which of the following statements should the nurse identify as an indication that the client needs further teaching? b. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. 3. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. a. The healthcare team should recognize the client as the center of the team. d. Explain oral hygiene to a client receiving chemo The nurse is reviewing some clients' prescriptions. Problems in Delegation: A Busy Day on the Floor - Quizlet The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. 1. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. 2. Client diagnosed with inoperative brain tumor who is confused. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Remind the client to tell the nurse when he has to urinate The charge nurse needs additional information to make a decision. d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. ATI Leadership and Management Questions - Leadership Management of Care Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? 1. e. an open perineal wound, 92. 4. c. Include intact skin at the wound edges in the culture Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. A charge nurse is making client care assignments. It is quicker to administer medications intravenously in the hospital c. When asking the client how he completes his ADLs Drag and Drop the items from one box to the other. The client can indicate desire for Do Not Resuscitate (DNR). a. The situation should be explored before bringing the supervisor in on the situation. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. and 16 g of fat. a. The charge nurse is planning the staff assignments for the clients on a neurological unit. Call the client's provider b. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Select all that apply The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. 1. Observe the client before taking further actions 1., 2., 4., & 5. Now, in Option #2, we see a dangerous prescription. 1. Refuse the overtime assignment, being prepared for disciplinary action. A charge nurse is making client care assignments. is a new graduate in orientation. These are appropriate tasks for an UAP to complete. The unit is short one staff member and will receive a nurse from the medical surgical unit. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Each state BON differs in that also some have treatment programs they administer themselves. a. In which situation should the nurse consult the client's advanced directive? 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. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. 4. b. Places the soiled linen in the floor before bagging it 2. the nurse responds, "don't worry, no one will harm your family." -Review a low-sodium diet for a client who has HTN 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 written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). 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. The surgeon initially prescribes a clear liquid diet. 1. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 3. The nurse received a client following surgery 8 hours ago. e. Dysuria, 49. This stage involves constructive efforts on the part of the group members Which of the following findings indicates that the client is meeting this goal? Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. Removing the client's dentures Complete blockage of the large intestine. 4. 1. a. The client is apparently stable and does not require any advanced assessment skills or specialized care. Select all that apply. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? Incorrect: This group of clients needs specific teaching. Which of the following physiological responses to prolonged immobility should the nurse expect? Simply accept the assignment since overtime is mandatory. Oral surgeon The client receives home health care and spends most of his day in a reclining chair. c. Changing a dressing d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) December 5, 2020. Which of the following is the priority action by the nurse? d. Counting radial pulse, 100. Anyone over age 18 can have an Advanced directive. D. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? A nurse is having difficulty caring for a client due to variables affecting the communication process. M4 Client Care Assignment.pdf - Making Client Care Place the pack on a sterile work surface This is an appropriate and safe action for the unlicensed nursing assistant to do. 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. b. Dons gloves to empty a urinary drainage device 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. The third client would be the one needing a dressing change. Which client should the nurse assess first? The abdominal pain is worsening. 3. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). The option does not say the client is terminal, in a vegetative state, or in a coma. Select all that apply. Write the letter of your choice on the answer line. This is the most stable of the four clients which places this client last to be seen. 2. }? benefactor of the world. This is a task that can be delegated to the LPN/LVN. Elderly client admitted 30 minutes ago with reports of constipation for four days. Handoff and Nursing Report Sheet. a. The nurse considers various ideas submitted by team members. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 5. It can result in muscle spasm and tissue damage. Which of the following instructions should the nurse include? The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. e. The urge to move the legs when trying to sleep, 66. What is the appropriate assignment? Which nurse should be assigned to care for this client? 2. 4. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 5. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Which of the following statements should the nurse identify as an indication that the client requires further clarification? Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". 3. 3. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. Client who is a diabetic experiencing diabetic neuropathy. Which of the following instructions should the nurse include? In what order should the nurse see the clients? It happened so long ago - just get over it!" 3. Which of the following actions indicates that the AP understands the principles of infection control? 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. Invite staff to contribute ideas on scheduling changes.
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