2. Select all that apply. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. The unit is short one staff member and will receive a nurse from the medical surgical unit. A person can be designated to make medical decision in the event the client cannot. Incorrect. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. A nurse is caring for a client who states, "I have got to get out of this hospital! December 5, 2020. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. 5. 3. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. The cause of the fall may be cardiac, but the question does not indicate this. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. Incorrect: The nurse is responsible for evaluating a client. 4. The RN requests reassigning at least one of the clients to another nurse. Measuring vital signs The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 4. Notify the nursing supervisor of the situation. b. Select all that apply. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Which of the following actions indicates that the AP understands the principles of infection control? This service began with the client's admission to the hospital INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. Now, in Option #2, we see a dangerous prescription. Provide an adaptive feeding device for the client Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. The nurse should do this when repositioning is needed. c. Tie linen bags securely at the top - Assisting a client to ambulate using a gait belt. a. Problems in Delegation: A Busy Day on the Floor - Quizlet c. Open the right flap with the left hand a. b. A charge nurse is making client care assignments. 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. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? Which of the following sites should the nurse plan to use to obtain the blood specimen? Checking capillary refill beneath the client's fingernail c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day 3. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. This includes medication enemas. a. The client should be assessed first to rule out respiratory difficulty and hemorrhage. This service began with the client's admission to the hospital, 18. 3. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. b. Semi-formed stools are great news! Dentures should be stored in a denture cup. Which of the following communication techniques should the nurse use during this phase? Call the family of a client suffering from dementia to discuss long term care placement. 1. 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. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Which of the following statements should the nurse identify as an indication that the client needs further instruction? 1. the nurse should delegate collection of which of the following specimens to DismissTry Ask an Expert Ask an Expert Sign inRegister Sign inRegister Home Ask an ExpertNew My Library Discovery Institutions Harvard University University of Georgia Maryville University d. Go to employee health services, b. 3. 1. When assigning nurses to patients, the charge nurse must consider the acuity of the patient's condition, the skills of the nurse, and the availability of other staff members. 1. 8. d. Sleep apnea Place the client in a lateral position 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. Notify the surgeon that the client wishes to withdraw informed consent for the procedure c. One nurse lifting the client's legs as the client uses a trapeze bar The nurse cannot allow the UAP to perform advanced tasks. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. a.) ATI Leadership and Management Questions - Leadership Management of Care c. The client's culture The nurse caring for the client at the time of death requests organ donation 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. Which of the following items should the nurse include on the lunch tray? A charge nurse is making client care assignments. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. Provides day to day direction and supervision to assigneddirect patient care staff . Allow the UAP to work without supervision. 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. Stand directly in front of the client Could you try contacting a support group Photo comes from the Greek word for light. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Following the teaching, the nurse asks the client to describe one physical effect. 3. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Tenderness over the symphysis pubis 5. This is a task that can be delegated to the LPN/LVN. The nurse could definitely be part of the committee. d. Routine acquisition of a urine specimen Evaluate client's safety risk factors. a. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. Assign a nursing assistant to help the client with self-care activities. d. I have a set of my brothers' crutches in the basement I can also use, a. d. Establishing the client's secondary medical diagnoses, b. 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). The charge nurse needs additional information to make a decision. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. Also, making a surgical bed for the client returning from surgery is a basic procedure. Which of the following findings should the nurse expect? b. d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. Drag and Drop the items from one box to the other. A charge nurse is observing a group of newly licensed nurses. Airborne Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. A nurse is preparing to move a client who is only partially able to assist up in a bed. 2. Which clients should be assigned to the CNA? The client receives home health care and spends most of his day in a reclining chair. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. b. I can detect the presence of carbon monoxide by a metallic odor Correct: Disconnecting NG tube suction is an appropriate task for the UAP. There are a total of 10 adult clients. b. The LPN/LVN can reinforce teaching. a. 3. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Measure urine output when client voids. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. a. d. Droplet, d. Bend at the knees when picking up an object, 98. Making client care assignments As the RN charge | Chegg.com Science Nursing Nursing questions and answers Making client care assignments As the RN charge nurse, you are preparing to make assignments for the oncoming shift in the medical-surgical unit. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. c. Raised toilet seats Monitor for GI upset 30 minutes after meals. d. I decline this opportunity at this time, b. No! (Select all that apply.) 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. Which of the following actions is the priority for the nurse to include in the client's plan of care? A client who is disoriented and awaiting transfer to a long-term care facility. A client requesting assistance packing his belongings for discharge later today., This is likely cholelithiasis, which will need to be checked out. The charge nurse knows what client would be most appropriate for this LPN? Aplastic anemia is a rare but serious condition. Only the state Board of Nursing can legally determine the LPN's scope of practice. d. Highly concentrated urine, 91. Serve food that have a hot/cold balance b. I will begin once the client's discharge order is written Reporting laboratory findings to a member of the client's family A nurse is caring for a client who has emphysema and has difficulty with mobility. a. c. Helping the client into the shower is a new graduate in orientation. Which of the following statements should the nurse make? Changing a colostomy bag. This could indicate a worsening of this client's condition. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. Temporary urinary retention (common for clients to develop after removal), 90. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Where on the body is each type of skin found? The nurse has been assigned four clients. c. I will place an area rug at the entry of my bathroom Select all that apply Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Turn on local news for up-to-date information on the train derailment. b. I will try to anticipate and avoid stressful situations when possible 3. 2. This service focuses on teaching the primary caregiver to meet the client's needs b. b. These are appropriate tasks for an UAP to complete. M4 Client Care Assignment.pdf - Making Client Care When the licensed person cannot determine this, the task should not be delegated. b. Summarization 6. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. Printable Nursing Brain SheetPrintable Nursing - soyu.caritaselda.es The client can indicate desire for Do Not Resuscitate (DNR). Inform the client of the need to avoid irritants such as carbonated beverages. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). 4. Besides yourself, there are the following staff: Your unit has 12 beds. 1. Richied5864 Richied5864 . Who should the nurse see first? An LPN/VN has been floated to the emergency room following a chemical plant explosion. 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. 2. 76. d. Motor impairment, 84. The nurse did not trust the new UAP. Nurses Report Sheet Template Nicu. b. The charge nurse is making client assignments for a neuro-medical floor. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen 1. The client is considered unstable until assessed by the nurse. What interventions can the nurse delegate to the LPN/VN? 1. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. d. Decreased calcium excretion, c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown), 27. 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. 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. 2. a charge nurse is making client care assignments for the day. which c. Explore the client's feelings about dietary modifications b. Emptying a urinary drainage bag for a client who has pneumonia Select all that apply. It's just not the right time for me to do this Nothing will get passed the complete blockage. d. Respite care is a continuation of psychological support after a family member dies. Phone report to the receiving nurse. Although this will require assessment, this client is not the priority at this time. 3. The third client that should be sent back for treatment is the female client stating she has been raped. a. d. Reduced blood viscosity, a. Auscultating heart sounds Reach around the pack and open the top flap away from the body 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. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. 4. 1. 6. c. Review another client's similar surgical experience 3. d. Lean back in the chair, b. 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. Show client who has conjunctivitis how to clean the eyes. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. b. I will keep the fluorescent ceiling light on in my room at night Respite care allows the primary caregiver time away from day-to-day care responsibilities c. Visual observation for nonverbal signs of pain c. Notify the nurse manager 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. For which of the following tasks should the nurse wear protective eye equipment. . A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. 3. Prepare a list of clients who could quickly be discharged or transferred. which of the following actions should the nurse perform? Focus on the client's present circumstances instead of his personal stories b. d. Remove tea and coffee from meal trays, b. Which of the following tasks should the nurse delegate to assistive personnel (AP)? 212 2. Client eating a simple-carb snack due to weakness. 3. D. A nurse instructs a female client about collecting a midstream urine sample. This protein is released by cells in the stomach. This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. Select all that apply. Fundamentals Practice Flashcards | Quizlet Ask the primary healthcare provider to suggest the best oral care procedure. Licenced practical nurses are a little less educated than registered nurses. 1. c. I'll clean the inside of the container with a wipe Which clients would be appropriate assignments for the LPN/LVN? This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Compartment syndrome could be developing which can impede circulation and cause nerve damage. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. b. I will call the doctor and get the prescription A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. A client requesting assistance packing his belongings for discharge later today.. 2. Schedule visiting times in two-hour increments so clients are not overwhelmed. A home health nurse is conducting a home safety assessment for an older adult client. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. 1. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. 4. Denial a. Which of the following actions should the nurse take? Which of the following should the nurse include as a criterion for applying restraints? a. This client could be transferred with traction still maintained. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Rewrite each incorrect sentence to correct the error. 2. 3. c. Respite care helps relieve pain and promote comfort A nurse who is on hormone replacement therapy. Select all that apply. Fruity breath. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Receive report from the emergency department (ED) on a new client. The supervisor can only send one LPN/LVN to the floor. 3. c. Rephrase statements the client does not hear b. 4. a. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. 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? 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. The abdominal pain is worsening. As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Relief of urinary retention We do not know the extent of her injuries based on what the option tells us. Wears a gown when entering the room of a client who requires contact precautions Handoff and Nursing Report Sheet. Places the soiled linen in the floor before bagging it A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 2. b. Donation costs are the responsibility of the donor's family and estate 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 is apparently stable and does not require any advanced assessment skills or specialized care. 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. c. Lock the medication in a room and finish preparing it after returning from the emergency 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. NUR 112 Practice Assessment Flashcards | Quizlet a. Correct: Traction should never be relieved without a primary healthcare provider's prescription. Select all that apply An Advance Directive includes a Living Will and a Medical Power of Attorney. 1., 2., 3., & 4. 1. The nursing supervisor may be able to assist with client care until another nurse can come in to work. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. (SATA) -Bathing a client who had an amputation 2 days ago. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. What should the nurse do first? Which of the following statements by the nurse would provide UAP with the best directions about an assignment? B. Which of the following tasks should the charge nurse reassign to a licensed nurse? Correct: If suspicious behavior occurs, it is important to keep careful, objective records. Have a pen and paper handy Obtain a client's consent 4. Disconnect client's nasogastric (NG) tube suction to allow ambulation. "The client is weak on the right side, so please assist the client with dressing . What client should the nurse assess first? Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. c. Washes and rinses her hands for 10 seconds Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. c. Review the client's progress toward personal objectives The healthcare team should recognize the client as the center of the team. c. Confrontation Use adult diapers to prevent frequent clothing changes b. Wash the area of the puncture thoroughly with soap and water a. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). 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. 1. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago 3. 2. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Teaching insulin self administration cannot be delegated to the LPN. Assign more daily tasks to the UAP. 1. c. Use an aggressive tone of voice Explain oral hygiene to a client receiving chemotherapy Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? 3. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. The other options may be correct but are not the best first action. 4. Lisinopril 20.0 mg PO daily c. The restraints should promote the client's safety and prevent injuries The nurse considers various ideas submitted by team members. Each state BON differs in that also some have treatment programs they administer themselves. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Which of the following instructions should the nurse give to the client prior to the procedure? c. Face shield Select all that apply Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Briefly assess every client. Focusing 4. What is the best response by the charge nurse? The UAP can assist clients with hygiene care, so it is within the scope of practice for the UAP to assist a client with a sitz bath for the postpartum client. d. Identifying the client by name when making a referral for home health services, 30. }? benefactor of the world. A nurse is having difficulty caring for a client due to variables affecting the communication process. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. b. 3. The LPN should refuse the intervention. This client should report an improved respiratory, not shortness of breath. 55. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. A nurse is caring for a client who is scheduled for an elective surgical procedure. a. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. However, providing care for missing teeth would also be within the LPN scope of practice. Which clients should be assigned to the CNA? 1. A nurse asks a client how he is feeling. 208 Assessing this client and titrating the diltiazem requires the skills of an RN. Which client should the nurse assess first? A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. 1. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. But the client does need to be assessed prior to the client with Crohn's disease who is improving. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? c. Leave a nightlight on in the client's room This client needs careful monitoring and specialized care. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following approaches should the nurse use when using confrontation? 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. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Which of the following physiological responses to prolonged immobility should the nurse expect? d. The nurse has already considered alternatives to restraints, a. d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74.