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Turn on local news for up-to-date information on the train derailment. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. A nurse is assessing a client who is experiencing prostatic hypertrophy. A nurse is engaging in relationship counseling with a male client. The last client would be the one needing dietary education. Which of the following statements should the preceptor make? Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Confrontation should occur in the presence of a charge nurse or supervisor. 5. a. Provide positive feedback to the UAP. The key word in the stem is first. It's just not the right time for me to do this Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. What was the hint? American Sickle Cell Anemia Association d. I will begin once the client's insurance company approves discharge coverage, b. Disconnect client's nasogastric (NG) tube suction to allow ambulation. 3. The nurse should perform which of the following activities in this space? Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. b. I will call the doctor and get the prescription Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Remind the client that a signed informed consent form is a legally binding document Encourage the client to use self-exploration a. b. I'm so sorry to hear about this c. Gender d. Establishing the client's secondary medical diagnoses, b. 1. Decide which choice fits best in the blank. Serve milk products separately from meals b. Take several shallow breaths during the procedure (Select all that apply.). c. imaginary Client one day post kidney transplant. 1. 5. 1., 4., & 5. Incorrect: It is out of the UAP's scope of practice to administer medication. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures 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. 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. A two-hour limit on visits discourages quality time. e. Talking with the client's partner, 79. During exacerbation, the client will have many diarrhea stools. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? b. Assigning tasks to an AP Which of the following communication techniques should the nurse use during this phase? Have another nurse guard the medication preparations until the nurse returns c. There is fluid leaking around the insertion site A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. b. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department a. I will keep spare crutch tips handy 2. A nurse is creating a discharge plan. 4. 5. b. Irrigate the NG tube with 100 mL of sterile water These individuals are selected by the charge nurse, and do not have to be nurses. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. This client could be transferred with traction still maintained. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. The report should contain consequences. A nurse is caring for a client who is postoperative. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? Which of the following infection-control precautions should the nurse use caring for this client? Cystogram reporting burning on urination. 1. b. Drag and Drop the items from one box to the other. - Assisting a client to ambulate using a gait belt. The nurse caring for the client at the time of death requests organ donation 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. Explain to the RN that all the nurses have the same number of clients. A client receives a wrong medication. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Correct. 4. A client receiving a blood transfusion that requires monitoring. 1. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Which of the following statements should the nurse identify as an indication the client needs further teaching? Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. 4. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. c. Environment d. Lean back in the chair, b. Education Elevating the head of the bed 30- 40 for the client post thoracotomy Symbolic communication c. The client's culture Charge Nurse - RN | Fresenius Karriere The client reports constipation for 4 days which may be an indication of worse problems. However, it is on the "Do Not Use" list of abbreviations because it can be confused with morphine sulfate (MSO4). Which actions should be instituted by each unit's charge nurse? Schedule visiting times in two-hour increments so clients are not overwhelmed. This should not be delegated to the LPN/LVN. 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). Reach around the pack and open the top flap away from the body d. Determine if the client uses hearing aids, b. Also, making a surgical bed for the client returning from surgery is a basic procedure. b. Summarization 1. A list of current medications is sent to the facility. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. The nurse cannot allow the UAP to perform advanced tasks. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? A nurse is admitting a client from a long-term care facility. 8 Steps for Making Effective Nurse-Patient Assignments Write the letter of your choice on the answer line. Placing a washcloth in the bathroom sink prior to cleaning. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? 1. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). Allow the UAP to work without supervision. a. A nurse is teaching a client about the physical effects of chemotherapy. A client with exacerbation of COPD reporting dyspnea. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. b. I will keep the fluorescent ceiling light on in my room at night This is the most stable of the four clients which places this client last to be seen. Perform the Heimlich maneuver 4. The nurse voices his concern to the charge nurse. The charge nurse's best response is to first obtain the needed information to make the best decision. b. 1. b. Select all that apply d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. Place the pack on a sterile work surface Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. 2. c. Decreased sodium excretion c. I will inspect my crutches everyday for signs of wear Correct: The client who has a cast and requires pain medication is a stable and predictable client. 3. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. The assignment process requires constant evaluation and reevaluation of information and priorities. b. Which of the following client statements should indicate to the nurse the need for additional teaching? This assumption is not appropriate, and the feelings and concerns of the client should be addressed. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Collecting I & O totals for unit clients at the end of shift. A charge nurse is making client care assignments. a. There are a total of 10 adult clients. The surgeon initially prescribes a clear liquid diet. 2. The client asks the nurse, "Why do I need that? What is the best care assignment for this client? Places the soiled linen in the floor before bagging it The client is getting better. Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client. Estimate the number of Calories in two tablespoons of peanut d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. What client should the nurse assess first? Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? a. Clarifying Incorrect: This group of clients needs specific teaching. A nurse is assessing a client at a follow-up clinic for acute low back pain. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. This could cause a medical emergency. A nurse is preparing a sterile field. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. The women's health charge nurse is making assignments for the next shift. Witness the client's signature 1. b. 4. Narrative interaction Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. a. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. What is the best first action for the nurse to take in order to achieve this goal? 6. 6. Client reporting epigastric pain and nausea after eating. The client states, "I'm feeling a bit nervous today." M2.4 Making Client Care Assignments - GECC.pdf - Course Hero Which of the following RNs should not be assigned to this baby? 4. This service focuses on teaching the primary caregiver to meet the client's needs Incorrect: What seems to be going on with this client? Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. c. The nurse may serve as a witness to informed consent for organ donation c. Include intact skin at the wound edges in the culture 2. b. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? A client has been admitted with folic acid deficiency anemia. 4. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. c. 214 I am feeling much better since my discharge from the hospital and I think my kidneys are working again." Client scheduled for breast reconstruction after mastectomy. Call the client's provider 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. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. 5. Which of the following responses should the nurse provide? Client reporting a headache and has a fruity breath. Incorrect: This is not completely practical for everyone. The nurse is using which of the following therapeutic communication techniques? CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. 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. Evaluate client's safety risk factors. c. Review another client's similar surgical experience 2. 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. 1. Which of the following actions indicates that the AP understands the principles of infection control? The client must understand the need for restraints The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN.