b. A nurse is discussing indications for urinary catheterization with a newly licensed nurse. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. c. Review a low-sodium diet for the client who has hypertension a. The nurse would then start the 24 hour urine once the 1st void has been discarded. 1. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Once the client is stable, the UAP could perform this task. c. I'll clean the inside of the container with a wipe This documentation should go to your manager. 2. c. I'll wear low heeled shoes from now on This client is not the nurse's first priority. d. Counting radial pulse This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. Elderly client who fell and fractured the left femoral neck. The area surrounding the insertion site feels warm to the touch Which of the following actions is the nurse's priority? This is an appropriate prescription. 2. 4. d. Social conversation, a. Nurses Report Sheet Template Nicu. Client with cast to right leg requiring pain medication. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. b. c. We administer all medications intravenously to clients in this unit Correct: If suspicious behavior occurs, it is important to keep careful, objective records. A nurse is caring for a client who has a mental health disorder. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. So what is wrong with option #1? Normally, red blood cells are flexible and round, moving easily through blood vessels. Asking for an explanation 2. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. 1. The cleint's family asks the nurse for info about this type of care. 5. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Gather supplies to prepare room for isolation. 2. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? 3. On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. 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. Incorrect: The nurse is responsible for monitoring a client. Pernicious Anemia Society The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 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. A nurse is caring for a client who is postoperative. 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. a. I will keep my walker at the end of my bed d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. The charge nurse might not have realized all the responsibilities of taking this team of clients. Report of feeling pressure b. I will begin once the client's discharge order is written Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Gather and apply dressings to open wounds. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? 7. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. A nurse is engaging in relationship counseling with a male client. 4. Which of the following findings should the nurse expect? Which clients should be assigned to the CNA? b. This is outside the scope of practice for the LPN/LVN. 1. Provide a between meal supplement to the client. A nurse instructs a female client about collecting a midstream urine sample. c. Leave a nightlight on in the client's room Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). The surgeon initially prescribes a clear liquid diet. Right forearm e. Feed a client who had a stroke 3 months ago, 31. 3. Aplastic Anemia Support Group. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. In what order should the emergency department triage nurse send these clients to a room for treatment? Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The client receives home health care and spends most of his day in a reclining chair. c. Open the right flap with the left hand 3. Inform the client of the need to avoid irritants such as carbonated beverages. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. A lack of rapid eye movement (REM) sleep 2. The charge nurse needs additional information to make a decision. 2. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. So, now you must decide which of these high priority clients should be seen in what order. Patient safety must remain the priority. Reporting laboratory findings to a member of the client's family 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. a. I will begin 48 hr before the client's discharge The area surrounding the insertion site feels warm to the touch, 61. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? A charge nurse is making client care assignments. Who should the nurse see first? Review the action of insulin therapy In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. b. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. Clients over the age of 65 must have a saline lock according to facility policy The client was lying on the floor next to his bed So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Report the incident to the charge nurse Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? c. Explain the risks and benefits of the procedure 3. To which of the following rooms should the nurse assign the client? An LPN/VN has been floated to the emergency room following a chemical plant explosion. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. Cardiac catheterization with a decreased pedal pulse below insertion site. 1. Select all that apply. b. 77. What was the rationale for this plan? 4. *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. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. Currently, your census is 11, with one empty bed. b. I'm so sorry to hear about this 6. 4. Describe the types of machining operations that can be performed on a lathe. Discuss the competency of the surgeon d. Discussing intake and output A nurse is teaching a client about carbon monoxide poisoning. Fruity breath. 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. Tenderness over the symphysis pubis d. Talk with the client's partner, b. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Notify the board of nursing (BON) that the float nurse is an alcoholic. What was the hint? 3. 3. Bargaining 2. In option #4, we see that the leading zero is missing from the prescription. 1. Incorrect: The nurse is responsible for evaluating a client. Select all that apply d. Message, 67. A goal for this client is to use proper body mechanics at all times. Select all that apply Something new could have occurred with the clients, making the assignments too heavy. Battery The client's self-report of pain severity, 88. & 5. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Notify the charge nurse of the observations. b. Of my three brothers and sisters, my sister Giselle has the best sense of humor. 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. Feedback d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago A nurse wants to find out a better way to perform oral care on unresponsive clients. Reach around the pack and open the top flap away from the body 3. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. Determine caregiver's stress level and coping strategies. c. Nonfat milk 3. c. Can you tell me why you chose me? Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. c. Changing a dressing 3. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 4. 2. A list of current medications is sent to the facility. 2. 4. 4. Phone report to the receiving nurse. Assessing this client and titrating the diltiazem requires the skills of an RN. a. Teaching about a medication b. I can detect the presence of carbon monoxide by a metallic odor 4. Assist ait to ambulate using a gait belt. A two-hour limit on visits discourages quality time. Determining the client's length of stay a. Auscultating heart sounds It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion).
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