A client with diabetes admitted for debridement of a foot ulcer. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. a. Clarifying The area surrounding the insertion site feels warm to the touch Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? 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. Estimate the number of Calories in two tablespoons of peanut Wears a gown when entering the room of a client who requires contact precautions -Review a low-sodium diet for a client who has HTN e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. b. Irrigate the wound with an antiseptic prior to obtaining the specimen a. a. 2. Empty the drainage bag at least every 8 hrb.) b. c. Provide the client with a diet high in protein But the client does need to be assessed prior to the client with Crohn's disease who is improving. Disconnect client's nasogastric (NG) tube suction to allow ambulation. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. 2. This is outside the scope of practice for the LPN/LVN. Incorrect: The nurse retains the responsibility for the delegated task. Perform the Heimlich maneuver b. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. A charge nurse is making client care assignments. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Incorrect: The nurse is responsible for evaluating a client. Report of feeling pressure Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. a. c. Blood-tinged urine 3. 2. c. Contact A nurse is caring for a client whose partner asks to speak with the nurse. 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. Start MgSO4 at 3g/hr IV 1. The LPN can monitor the wound and provide care to the PEG insertion site. Once the client is stable, the UAP could perform this task. Besides yourself, there are the following staff: Your unit has 12 beds. a. This includes medication enemas. What task would be best to assign to the LPN/LVN? b. Massage any bony prominences to promote circulation a. 3. 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. 2. 1. b. Currently, your census is 11, with one empty bed. Most of the following sentences contain errors in the use of modifiers and comparisons. 1. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. 208 3. A nurse is admitting a client from a long-term care facility. c. Hallucinations at the onset of sleep Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. 2. A nurse in a clinic is caring for a client who reports pain, crepitus, and a popping sound is his temporomandibular joint. a. c. Face shield 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. Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. This is a diabetic clinic. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. Client prescribed antibiotics for cystitis. 1. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. Removing the client's dentures 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. 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. 3. Teaching about a medication c. Notify the nurse manager Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. In what order should the nurse see the clients? 2. Placing a washcloth in the bathroom sink prior to cleaning. One important aspect is encouraging the flow of ideas between management and staff members. b. A charge nurse is making client care assignments. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. The charge nurse is planning the staff assignments for the clients on a neurological unit. Which of the following responses should the nurse provide? Obtain a bedside commode for the client's use When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Reach around the pack and open the top flap away from the body, 53. 6. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 3. Which of the following actions should the nurse include in the plan? Incorrect: The RN is responsible for assessment and evaluation of clients. Relax her abdominal muscles when she lifts an object 1. c. Assist the client to the floor and begin mouth-to-mouth 1. 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. b. - Assisting a client to ambulate using a gait belt. 4. Remind the client to tell the nurse when he has to urinate The nurse voices his concern to the charge nurse. e. Suctioning a client's new tracheostomy tube, 93. 1. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. Incorrect: Moistening the dentures will ease insertion. Read all the current literature related to oral care on unresponsive clients. This would be an acceptable task to assign to the UAP. c. They tend to use more verbal communication 2) Assist a client to ambulate using a gait belt. Which clients should be assigned to the CNA? For which of the following tasks should the nurse wear protective eye equipment. d. Remove tea and coffee from meal trays, b. 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. Broth a. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. 4. 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. A family member requests that the nurse apply restraints. Write the letter of your choice on the answer line. 3. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. Hanging a new bag of total parenteral nutrition (TPN). a. 3. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Yes! 3. 1. This client is not the nurse's first priority. 2., 3. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. Send a day's worth of medications with the client to the receiving facility. A client with COPD complaining of shortness of breath on exertion. This stage is when testing occurs to identify boundaries of interpersonal behaviors Correct: The UAP can remind the client to do something that has already been taught by the nurse. The surgeon initially prescribes a clear liquid diet. This can prevent harm to client's. A home health nurse is conducting a home safety assessment for an older adult client. b. 2. Which nurse should be assigned to care for this client? What would the approximate meaning of photoelectric be, based on these root words? b. I will try to anticipate and avoid stressful situations when possible 2. a. Auscultate breath should at least ever 2 hr c. I'll bear weight on my ankle for 10 minutes every hour Phone report to the receiving nurse. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. 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 distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Clients over the age of 65 must have a saline lock according to facility policy Denial Assist client to brush and floss teeth. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Prepare a list of clients who could quickly be discharged or transferred. Documentation is a communication tool for the interprofessional health care team. Refuse the delegated intervention. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. 1. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. b. the nurse responds, "don't worry, no one will harm your family." a. Ask the float nurse, "Have you been drinking?" Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Discuss the competency of the surgeon Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Nursing questions and answers. To which of the following rooms should the nurse assign the client? 2. 6. The charge nurse's best response is to first obtain the needed information to make the best decision. The cause of the fall may be cardiac, but the question does not indicate this. Places the soiled linen in the floor before bagging it The nursing supervisor may be able to assist with client care until another nurse can come in to work. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. 1. Call the client's provider Place the client in low Fowler's position Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? Identify and assess each incoming client. 2. Pick up the tray and tell the UAP that they didn't do a good job. A nurse is administering a cold therapy application to a client. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. Which of the following responses should the nurse make? Removing the abdominal dressing Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. Encourage the client to be more cooperative. Which of the following items should the nurse include on the lunch tray? 1., 2., 3., & 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. What is the best response by the charge nurse? c. Confrontation 4. A nurse is caring for a client who has a hip fracture that requires surgical repair. It also helps the client deal with issues that are important to him), 19. d. Highly concentrated urine, 91. The third client that should be sent back for treatment is the female client stating she has been raped. Assist a client to ambulate using a gait belt. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. c. Malpractice Select all that apply American Sickle Cell Anemia Association Accept assignment, documenting personal concerns regarding work conditions. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Asking for an explanation Incorrect: The charge nurse does not have to assess every client. Determine caregiver's stress level and coping strategies. Warm the feeding solution to the body temperature Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. A goal for this client is to use proper body mechanics at all times. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. A nurse is caring for an older client who is at risk for skin breakdown. A nurse is implementing direct nursing care for a group of clients in an acute care facility. 4. a. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. 4. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Client scheduled for breast reconstruction after mastectomy. Which response by the LPN is appropriate in response to the inappropriate delegation? a. Shakes the soiled linen to remove any toilet paper remnants Decide which choice fits best in the blank. Explain to the RN that all the nurses have the same number of clients. 4. Notify the surgeon that the client wishes to withdraw informed consent for the procedure In what order should the emergency department triage nurse send these clients to a room for treatment? d. Anger, b. A nurse has completed an informed consent form with a client. Lumbar puncture reporting a headache. The provider must renew a restraint prescription every 8 hr. We do not know the extent of her injuries based on what the option tells us. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. b. Wash the tablet off with alcohol and place it in a clean medicine cup This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Which of the following actions should the nurse take? The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 4. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. b. What is the major histological difference between thick and thin skin? 2. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. d. Identifying the client by name when making a referral for home health services, 30. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. a. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. b. Explain oral hygiene to a client receiving chemotherapy Place in priority order. The nurse should perform which of the following activities in this space? Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? c. Request a tray without pork a. The nurse should assess the client for which of the following expected outcomes after catheter removal? So what is wrong with option #1? Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. To confirm the placement of the NG tube Narrative interaction This referral would be appropriate. The RN with 10 years' experience pulled from the ER. Temporary urinary retention (common for clients to develop after removal), 90. 3. Thoracentesis reporting shortness of breath. 1. These individuals are selected by the charge nurse, and do not have to be nurses. Correct. Select all that apply.
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