Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. When determining if the client is eating a well-balanced diet Rewrite each incorrect sentence to correct the error. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. c. Review a low-sodium diet for the client who has hypertension d. Do you think crying will help? Assist a client to ambulate using a gait belt Incorrect: There are situations in which the LPN must notify the primary healthcare provider. Select all that apply The facility has insurance that will cover malpractice litigation The nurse also needs to be aware of the color and amount of urine voided. c. Provide the client with a diet high in protein b. 3. c. Inform the surgical team to cancel the client's surgery UAPs can assist with elimination and are taught how to measure output. A nurse is caring for a client who has a wound infection. 1. So what is wrong with option #1? The client then states, "I have changed my mind and do not want to have the procedure done." The surgeon initially prescribes a clear liquid diet. b. 2. 1. Decreased or suppressed respiration are priority. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. 4. c. Distended bladder Assign more daily tasks to the UAP. They have found my address and are coming for my family!" This documentation should go to your manager. A charge nurse is making client care assignments. Compartment syndrome could be developing which can impede circulation and cause nerve damage. 4. b. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. B. c. Helping the client into the shower Select all that apply A nurse receives a client care assignment from the charge nurse that he believes is unfair. 5. 3. 3. Select all that apply I'm drinking plenty of fluids." e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. Following a large hurricane, multiple clients arrive at the emergency room for treatment. 4. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. Placing the traction weights on the bed to transfer the client to x-ray. This is an elderly client who is a new admit. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. Have another nurse guard the medication preparations until the nurse returns c. Discard any residual gastric contents When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. 1. A school-aged child with a fractured femur who is in balanced suspension traction. The client with cystitis is stable and has a predictable outcome. a. I will wear gloves when removing food from the freezer Assist a client to ambulate using a gait belt Notify the charge nurse of the observations. A medical-surgical LPN has been sent to a short-staffed pediatric unit. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? (Select all that apply.). The nurse caring for the client at the time of death requests organ donation b. Provide positive feedback to the UAP. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 3. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. 4. 4. 3. The third client that should be sent back for treatment is the female client stating she has been raped. (Select all that apply.). To remove gastric acid that might cause dyspepsia Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. The client is reporting anxiety, discomfort, and a feeling of bloating. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Places the soiled linen in the floor before bagging it 1. d. Left forearm, b. b. Incorrect: The nurse is responsible for evaluating a client. Pain 2. Client with chronic emphysema experiencing mild shortness of breath. a. d. Perception Lumbar puncture reporting a headache. 2. Use double bagging to remove soiled linen from the client's room A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following statements by the student indicates understanding of the discussion? Allow the UAP to work without supervision. 1. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. 10. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 2. a. c. Environment d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. It can result in muscle spasm and tissue damage. 1. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. A nurse is caring for a client who states, "I have got to get out of this hospital! Which clients should be assigned to the CNA? Feed the client after warming the food. c. Explore the client's feelings about dietary modifications A float nurse arrives on the unit to assist in the care of clients for the shift. The area surrounding the insertion site feels warm to the touch, 61. Donning gloves and using a gauze pad to grasp and remove dentures Which of the following actions is the nurse's priority? 4. 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. 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. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. 4. An adolescent client post appendectomy reporting pain. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. 1. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. A client with epilepsy reporting an odd smell in the room. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Involve the client in their plan of care. a. The nurse has another priority. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? Symbolic communication A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. It is quicker to administer medications intravenously in the hospital 5. b. 4. d. Complete an incident report, 70. 3. 1., 2., 3., & 4. For which of the following actions should the nurse intervene? Client with a T-5 spinal cord injury beginning rehabilitation therapy. a. Bathe a client who had an amputation 2 days ago What is the best response by the charge nurse? c. Malpractice 3. Stand directly in front of the client Remind the client that a signed informed consent form is a legally binding document Removing the client's dentures The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. The cause of the fall may be cardiac, but the question does not indicate this. What action should the nurse implement first to ensure client safety? It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. 1. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Providing a passive response Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. A client who is disoriented and awaiting transfer to a long-term care facility. 4. b. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. b. Two hours . Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. d. They disclose more personal information, a. Currently, your census is 11, with one empty bed. Thus, the tasks involve successful management of the charge nurse's responsibilities. The nurse prefers to check all vital signs on all clients. He charge nurse is making client care assignments for the evening shift. One nurse lifting as the client pushes with his feet b. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. A nurse is caring for a client whose partner asks to speak with the nurse. d. Let's wait until tonight to see if he continues his behavior, 63. Pernicious Anemia Society d. Message, 67. Assessing this client and titrating the diltiazem requires the skills of an RN. 1. The client can indicate desire for Do Not Resuscitate (DNR). Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. The client was lying on the floor next to his bed d. Sleep apnea Call the client's provider Alcoholic Anonymous A nurse is teaching a client who has a history of falls about home safety. 55. 3. Cardiac catheterization with a decreased pedal pulse below insertion site. 2. Review a low-sodium diet for a client who has hypertension. c. Assist the client to the floor and begin mouth-to-mouth Place in priority order. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? 3. 1. e. Talking with the client's partner, 79. e. an open perineal wound, 92. This would be out of the UAP's scope of practice. Reach around the pack and open the top flap away from the body, 53. This is normal for clients with hemorrhoids. c. I'll need to shave the hair off the skin where I place the electrodes Which of the following items should the nurse include on the lunch tray? Which of the following responses should the nurse provide? 1) Bathe a client who had an amputation 2 days ago. Have another nurse finish preparing the medications 3. Aplastic Anemia Support Group. 1. Nothing life threatening. b. I will come back later and we can talk 1. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. a. A nurse is performing care activities for a client in the zone of touch that requires his consent. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. 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. 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. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? b. I will bear the weight of my body on my hands a. d. Water heater temp 54.4 C (130 F) A home health nurse is conducting a home safety assessment for an older adult client. a. This can prevent harm to client's. c. Do not eat or drink anything the morning of the test 1. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 4., & 5. c. I'll wear low heeled shoes from now on Which of the following statements should the nurse make? Incorrect: Atrial fibrillation places the client at risk for blood clots. What task would be best to assign to the LPN/LVN? This client is not the nurse's first priority. Which of the following of Erikson's developmental stages should the nurse consider in the planning? Notify the primary healthcare provider. Give magnesium citrate 296 mL at 3 PM today. The RN with 8 years' experience in the Intensive Care Unit. a. I'll sit with my knees lower than my hips Elderly clients have special fluid and electrolyte issues after a fall. A nurse is assessing a client at a follow-up clinic for acute low back pain. 4. A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Incorrect: This is not completely practical for everyone. a. I'll apply ankle to my ankle today and tomorrow a. 4. b. 3. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. 1. Which of the following types of communication breakdown does this response represent? 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain Use adult diapers to prevent frequent clothing changes 1. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. 5. d. Reduced blood viscosity, a. Auscultating heart sounds 4. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Performing passive range of motion (ROM) on the client with right sided paralysis. 1. b. b. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Nursing questions and answers. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Correct: The client who has a cast and requires pain medication is a stable and predictable client. The client reports constipation for 4 days which may be an indication of worse problems. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. The nurse cannot allow the UAP to perform advanced tasks. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. b. 2. 2. Administering 3 g/hr IV of morphine would be extremely dangerous. a. Bathtub with rails 4. & 3. d. I decline this opportunity at this time, b. In what order should the nurse see the clients? Measure urine output when client voids. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. a. I will keep my walker at the end of my bed Select all that apply 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. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. b. I should call my doctor if I find it harder to concentrate c. I will cover the catheter so he cannot see it Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Risperidone .5 mg PO daily Which task would be appropriate for the nurse to assign to an LPN/VN? 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. Provides day to day direction and supervision to assigned direct patient care staff. Assist client to brush and floss teeth. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. 2. The nurse should call for immediate help so that a safe care environment is maintained for all clients. Client who is a diabetic experiencing diabetic neuropathy. Bargaining It is within the LPNs scope of practice to administer antibiotics. d. Proceed with the preparation of the patient's surgical procedure, 15. Which of the following methods should the nurse plan to use? Place the client in a lateral position Correct: The UAP can remind the client to do something that has already been taught by the nurse. c. Use an aggressive tone of voice A charge nurse is making client care assignments. (Select all that apply.) 2. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. 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. 5. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. b. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Moistening the dentures prior to inserting them Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. 2. This determination is needed to assure client safety is being considered. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. Client reporting a headache and has a fruity breath. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? 3. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. 2. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. e. Dysuria, 49. c. Palpating for pedal edema Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. c. Changing a dressing 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. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. c. Paraphrasing d. Determine if the client uses hearing aids, b. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. The last client would be the one needing dietary education. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. 77. The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Although this will require assessment, this client is not the priority at this time. Which of the following items should the nurse offer the client? A nurse is caring for a client who has limited hand movement. The other options may be correct but are not the best first action. 1. c. I suggest you talk with a mental health counselor about your concerns A client with atrial fibrillation currently on a diltiazem drip. a. 1. 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. Now, in Option #2, we see a dangerous prescription. The client asks about his medications and their effects. 1., 2., 3., & 4. An LPN/VN has been floated to the emergency room following a chemical plant explosion.
