1. The nurse should not lecture, scold or argue with the float nurse. Incorrect: The nurse cannot assign teaching to the UAP. Monitor for behavioral changes. 2. The charge nurse on the postpartum unit is making assignments. Patient safety must remain the priority. 5. Which of the following client statements should indicate to the nurse the need for additional teaching? Which client should the nurse assess first? 4. Of my three brothers and sisters, my sister Giselle has the best sense of humor. Teaching about a medication c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day 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. 2. a. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. c. Discard the tablet and obtain another dose of medication c. Respite care helps relieve pain and promote comfort 3. 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. Initiate oxygen and IV lines as needed. What would the approximate meaning of photoelectric be, based on these root words? Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. c. I will begin upon the client's admission to the facility The charge nurse is making client assignments for a neuro-medical floor. d. I decline this opportunity at this time, b. Provides day to day direction and supervision to assigneddirect patient care staff . Which of the following instructions should the nurse include? A float nurse arrives on the unit to assist in the care of clients for the shift. 4. 1. Select all that apply. This would be out of the UAP's scope of practice. Tenderness over the symphysis pubis d. Left forearm, b. 1. A nurse is assessing a client who is experiencing prostatic hypertrophy. A two-hour limit on visits discourages quality time. 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. 3. 3. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. This referral would be appropriate. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 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. 3. 2. An adult (18 years or older) can create an advanced directive. a. Gloves Soaking the dentures in hot water 1., 3, & 4. b. Semi-formed stools are great news! e. The urge to move the legs when trying to sleep, 66. b. Verbalize understanding of how the client feels 6. Which of the following actions should the nurse take prior to administering the tube feeding? 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. 5. 55. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. The client attempted to climb over the side rails and fell 1. a. I wish I didn't have to attach the electrodes to my skin d. Wait to discuss the behavior in the presence of others, a. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. b. 1. Teach the UAP to change surgical dressings. Evaluate client's safety risk factors. Which of the following actions should the nurse take first? Fruity breath. So what is wrong with option #1? 3. c. Washes and rinses her hands for 10 seconds 4. c. There is fluid leaking around the insertion site Which of the following infection-control precautions should the nurse use caring for this client? The assignment process requires constant evaluation and reevaluation of information and priorities. Provide an adaptive feeding device for the client, 50. An increased temperature will have a direct effect on the brain's metabolism and function. d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. c. Hallucinations at the onset of sleep The nurse suggest that the family might need to respite care services. a. b. Make referrals to community services. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Client one day post kidney transplant. 1., 4., & 5. 3. The nurse is using which level of communication at this time? a. Alert all off-duty personnel to stand by in case of call- in. 6. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Elderly client admitted 30 minutes ago with reports of constipation for four days. Client reporting epigastric pain and nausea after eating. c. Face shield Prepare a list of clients who could quickly be discharged or transferred. a. Auscultating heart sounds Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Include any relevant statements the client made about the ulcer, 64. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) What proposal would the nurse determine to best meet the needs of families and clients in long term care? It contains a blank and is followed by four answer choices. c. Include intact skin at the wound edges in the culture A charge nurse is making client care assignments. The nurse has another priority. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. 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. Assist a client to ambulate using a gait belt. b. b. 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. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Once the client is stable, the UAP could perform this task. This is not a situation that requires the LPN to notify the primary healthcare provider. c. Document in the client's medical record that she completed an incident report 2. 2. Incorrect: The RN is responsible for assessment and evaluation of clients. A nurse is prioritizing care for two clients at the start of the shift. If you give the magnesium citrate, which is a laxative, what will happen? c. Review another client's similar surgical experience This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Evaluate pain relief after narcotic administration. 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. Changing the subject A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. 10. Who should the nurse see first? Only a plain enema or soap enema can be given by the UAP. 1. 1. a. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. b. This client is at a high risk of infection. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Remind the client to avoid tight fitting clothes. A nurse is caring for a client who is postoperative. a. Electric cords behind the furnitrure b. Grape juice a. 1. Channel Which of the following pieces of PPE should the nurse remove first? The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. A nurse wants to find out a better way to perform oral care on unresponsive clients. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. c. Review the client's progress toward personal objectives Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. The nurse should do this when repositioning is needed. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. Documentation is a communication tool for the interprofessional health care team. Normally, red blood cells are flexible and round, moving easily through blood vessels. 3. What is the best first action for the nurse to take in order to achieve this goal? The nurse is reviewing some clients' prescriptions. a. Placing a washcloth in the bathroom sink prior to cleaning. 5. 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. Correct: Hot water may damage dentures so intervention is needed. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Select all that apply. Based on these findings, to which of the following providers should the nurse request a referral for the client? 4. 4. 3. d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. The client reports constipation for 4 days which may be an indication of worse problems. 3. Triage and assign color-coded tags to each client. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. A nurse who is breastfeeding her 4 month old. A nurse is engaging in relationship counseling with a male client. Which of the following responses should the nurse make? a. b. 4. 2. This would be an acceptable task to assign to the UAP. b. I will begin once the client's discharge order is written C-section planning discharge, postpartum infection, mastectomy. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. 2. c. I'll need to shave the hair off the skin where I place the electrodes Hearing loss 2. 1. The women's health charge nurse is making assignments for the next shift. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. The nurse does not know the skills of the new UAP. Encourage the client to use self-exploration Assign more daily tasks to the UAP. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. We do not know the extent of her injuries based on what the option tells us. Airborne Which of the following responses should the nurse make? Incorrect: This prescription is written correctly. c. Distended bladder 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 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). b. Wash the area of the puncture thoroughly with soap and water d. Mask, 83. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. 1. a. I'll urinate a little then stop a. 3. Delegate 2 nurses to work with the client. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? Incorrect: No, the monitoring is too specific for the med-surg nurse. Provides safe, effective delivery of patient care in . 3. 3. c. Notifying the provider of physical exam findings A nurse is developing a plan of care for a client who practices Islam. 3. The area surrounding the insertion site feels warm to the touch, 61. A client with a fractured right humerus who reports the cast is too tight. b. Remind the client that a signed informed consent form is a legally binding document Which of the following explanations should the nurse provide? Select all that apply. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Checking capillary refill beneath the client's fingernail *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. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. 2. Notify the primary healthcare provider of transfer completion. b. Empty the drainage bag at least every 8 hrb.) Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. 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. Report of feeling pressure 1. Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? 4. Incorrect: The RN is responsible for collecting data. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage A nurse is caring for an older client who is at risk for skin breakdown. 3. Which of the following should the nurse include as a criterion for applying restraints? A goal for this client is to use proper body mechanics at all times. 3. 2. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Which of the following actions should the nurse take regarding informed consent? The client must understand the need for restraints Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. c. Hallucinations at the onset of sleep, 65. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). The client can indicate desire for Do Not Resuscitate (DNR). 4. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. 1, 3 & 5. 2. 4. 2. Report the incident to the charge nurse d. Lean back in the chair, b. 4. 1. & 3. Asking for an explanation 4. The best practice committee works to improve clinical practice based on current research. Incorrect: This client is exhibiting early signs of increased intracranial pressure. 2. 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. a. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. a. Collecting I & O totals for unit clients at the end of shift. Limit the client's fluid intake in the evening 1., 2., & 5. What is the primary factor for the charge nurse to consider when delegating care? Pick up the tray and tell the UAP that they didn't do a good job. The nurse cannot allow the UAP to perform advanced tasks. c. Nonfat milk Remember, pick the killer answer first! 2. 3. Although this will require assessment, this client is not the priority at this time. Place the pack on a sterile work surface 1. Review the action of insulin therapy Question: A charge nurse is making client care assignments. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." A charge nurse is making assignments for an oncoming shift. (Select all that apply.) In what order should the nurse see the clients? b. This center functions as 'information central', where all plans or activities are coordinated and determined by those personnel. Right forearm A nurse is caring for a client within the intimate zone of the client's personal space. A client requesting assistance packing his belongings for discharge later today., 2. 76. Obtain a client's consent When staff do not feel vested in any new process, there is a sense of underappreciation. 3. Which of the following sites should the nurse plan to use to obtain the blood specimen? Hold the penis at a 30 to 45 degree angle when inserting the catheter Twist at the waist when she moves an object to one side Make nursing assignments appropriate to the skill level . The RN requests reassigning at least one of the clients to another nurse. The charge nurse knows what client would be most appropriate for this LPN? 1., 2., 3., & 4. & 5. In which situation should the nurse consult the client's advanced directive? 1. A nurse is assessing a client at a follow-up clinic for acute low back pain. Discuss the competency of the surgeon 2. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. 1. The provider must renew a restraint prescription every 8 hr. Feed a client that had a stroke 3 months ago. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. c. Contact A nurse is caring for a client who is postoperative following an appendectomy. b. a. I'll sit with my knees lower than my hips a. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. Yes! Elevating the head of the bed 30- 40 for the client post thoracotomy A nurse is assessing a client who has narcolepsy. The client is apparently stable and does not require any advanced assessment skills or specialized care. A school-aged child with a fractured femur who is in balanced suspension traction. What was the hint? Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. The nurse voices his concern to the charge nurse. Did you recognize ureterolithiasis as "kidney stones"? 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. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 2. Which of the following tasks should the nurse delegate to AP? Which actions should be instituted by each unit's charge nurse? 1. What client should the nurse assess first? b. 4. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. c. Changing a dressing a. The option does not say the client is terminal, in a vegetative state, or in a coma. The nurse has just completed a 12 hour shift. Witness the client's signature Which of the following statements should the nurse identify as an indication that the client needs further teaching? Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". d. Explain oral hygiene to a client receiving chemo 3. d. I will place a bath seat in my shower to use when I bathe, b. Return any fresh linen not used for a client to the linen supply area a. 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. d. Counting radial pulse 4. 4. Accept assignment, documenting personal concerns regarding work conditions. The RN with 10 years' experience pulled from the ER. 2. 1 The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Furosemide 40 mg PO q.d. c. Irrigating a client's abdominal wound The spouse can rescind the Advance Directive if the client becomes unresponsive. Cardiac catheterization with a decreased pedal pulse below insertion site. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. 4. The other options may be correct but are not the best first action. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 2. A nurse just back from maternity leave. Changing a colostomy bag. c. Paraphrasing 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. Now, in Option #2, we see a dangerous prescription. Incorrect: Informing is the same thing as teaching. When determining if the client is eating a well-balanced diet What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? leadership management of care nurse on unit is providing care for group of clients. (SATA) -Bathing a client who had an amputation 2 days ago. Correct. The nurse should call for immediate help so that a safe care environment is maintained for all clients. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. c. 214 This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 2. a. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. d. Complete an incident report, 70. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Request a prescription for a medication to ease the client's anxiety Aplastic anemia is a rare but serious condition. a. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. 1. To which of the following rooms should the nurse assign the client? d. principal. (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. d. Highly concentrated urine, 91. a. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Each state BON differs in that also some have treatment programs they administer themselves. The nurse considers various ideas submitted by team members. Which of the following interventions should the nurse include? Correct: The client has the right to be involved in the decision making of their care. 1) Bathe a client who had an amputation 2 days ago. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? 4. b. 4. }? benefactor of the world. 1. When a family member asks how respite care can help, which of the following responses should the nurse provide? Notify the primary healthcare provider. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. c. Assist the client to the floor and begin mouth-to-mouth Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. 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. Injuries from a motor-vehicle accident can be life threatening. 3. d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. Observe the client before taking further actions For which of the following actions should the nurse intervene? 2. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. UAPs can assist with elimination and are taught how to measure output. Document what the nurse believes was the cause of the ulcer development 3. The nurse is focusing on which of the following elements of the communication process? The facility has insurance that will cover malpractice litigation b. Dons gloves to empty a urinary drainage device 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. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. Well, do you see the q.d.? The expected standard of care was strict bed rest), 96. This client could be transferred with traction still maintained. M2.4 Making Client Care Assignments - GECC As the RN charge nurse, you are preparing to make assignments for the oncoming shift on the medical-surgical unit. Something new could have occurred with the clients, making the assignments too heavy.

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