b. Summarization 1. Autonomy vs shame and doubt A client requesting assistance packing his belongings for discharge later today., c. Open the right flap with the left hand 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. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. Which of the following actions should the nurse take to assist the client with feeding? What is the best response by the charge nurse? This can prevent harm to client's. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 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. b. Only a plain enema or soap enema can be given by the UAP. b. c. Physical therapist 3. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. b. I'll do exercises that strengthen my abdominal muscles Client reporting epigastric pain and nausea after eating. Which of the following statements should the nurse make? 1. Which of the following actions by the nurse is considered an indirect nursing care activity? c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day Gather and apply dressings to open wounds. 2. Because the charge nurse observes and weighs . Elderly client admitted 30 minutes ago with reports of constipation for four days. Incorrect: Informing is the same thing as teaching. Teach the UAP to change surgical dressings. 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). b. Negligence The nurse has received the change-of-shift report. 3. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Which of the following actions should the nurse take first? Places the soiled linen in the floor before bagging it Making client care assignments As the RN charge | Chegg.com Science Nursing Nursing questions and answers Making client care assignments As the RN charge nurse, you are preparing to make assignments for the oncoming shift in the medical-surgical unit. Something new could have occurred with the clients, making the assignments too heavy. The nurse should initiate a referral with which of the following members of the interprofessional health care team? a. c. Can you tell me why you chose me? Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. a. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. d. Transporting a cerebrospinal fluid specimen to the lab However, there are some basic points which are standard among all facilities. Evaluate client's safety risk factors. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. The charge nurse is planning the staff assignments for the clients on a neurological unit. 2. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? This protein is released by cells in the stomach. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. 76. Obtain a client's consent A nurse is performing care activities for a client in the zone of touch that requires his consent. 4. Incorrect: This again is assessment which is the role of the RN only. c. The restraints should promote the client's safety and prevent injuries Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. Read all the current literature related to oral care on unresponsive clients. A post-cardiac catheterization needing assistance with bedpan. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. a. Plan all care to be completed in early morning to allow afternoon for visitation. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. 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. c. Distended bladder A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. 6. This stage involves constructive efforts on the part of the group members Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. 3. a. 2. Which tasks should the charge nurse delegate to the nursing assistant? Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. A nurse is teaching a client who has a history of falls about home safety. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. A charge nurse is making client care assignments. which of the following actions should the nurse perform? b. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. Client diagnosed with Guillain-Barre' who is receiving ventilator support. The expected standard of care was strict bed rest), 96. b. b. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. 1., 2., 3., & 4. A nurse is caring for a client who expresses anxiety about his impending surgery. b. Select all that apply c. Consensus evolves in this stage 1. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. Have another nurse finish preparing the medications Which task is appropriate for the nurse to delegate to the experienced nursing assistant? a. Triage and assign color-coded tags to each client. A skill for which the ap has received instruction the - Course Hero Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 2. assignmentcafe.com - A charge nurse is making assignments for nursing Focusing The other options may be correct but are not the best first action. 4. a. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. a. 4. Removing the client's dentures 2. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". 3. (Select all that apply.) This client could be transferred with traction still maintained. The third client would be the one needing a dressing change. A nurse is assessing a client at a follow-up clinic for acute low back pain. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. A nurse is caring for a client whose partner asks to speak with the nurse. A client receiving a blood transfusion that requires monitoring. Thoracentesis reporting shortness of breath. A nurse is admitting a client from a long-term care facility. Simply accept the assignment since overtime is mandatory. d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. They have found my address and are coming for my family!" 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) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) Correct: This group of clients is primarily med surgical. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. the nurse responds, "don't worry, no one will harm your family." The nurse cannot allow the UAP to perform advanced tasks. What action should the nurse take after mistakenly administering the wrong medication? d. I will place a bath seat in my shower to use when I bathe, b. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. Client reporting a headache and has a fruity breath. Solved 4. A charge nurse is making client care assignments. | Chegg.com 3. Confrontation should occur in the presence of a charge nurse or supervisor. Which of the following info should the nurse include? c. Do not eat or drink anything the morning of the test Select all that apply. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Which of the following actions should the nurse include in the plan? c. Discard any residual gastric contents The client reports constipation for 4 days which may be an indication of worse problems. a. There are a total of 10 adult clients. The RN with 5 years' experience in the Labor and Delivery unit. Electric cords behind the furnitrure Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. c. Providing anticipatory guidance to a client in crisis The client with chronic emphysema has expected shortness of breath. b. 1. 3. Notify the primary healthcare provider of transfer completion. Correct: The client who has a cast and requires pain medication is a stable and predictable client. d. Explain oral hygiene to a client receiving chemo A nurse is preparing to move a client who is only partially able to assist up in a bed. 5. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. a. 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. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. a. So what is wrong with option #1? 1. Monitor client for pain while assisting with ambulation. 4. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. d. Remove and reinsert the NG tube, a. 1, 3 & 5. Which of the following statements should the nurse identify as an indication that the client needs further instruction? 3. Which nurse should be assigned to care for this client? 1 5. Select all that apply 2. 5. 3. 1. leadership management of care nurse on unit is providing care for group of clients. Which client should the nurse assess first? Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? Allow families unlimited visitation around the clock to meet their schedules. What would the approximate meaning of photoelectric be, based on these root words? Respite care allows the primary caregiver time away from day-to-day care responsibilities This could cause a medical emergency. The nurse should not lecture, scold or argue with the float nurse. Remember airway, breathing and circulation (ABCs). Make nursing assignments appropriate to the skill level . Call the family of a client suffering from dementia to discuss long term care placement. Client one day post kidney transplant. b. 3. b. To remove gastric acid that might cause dyspepsia The reason for the UAP not feeding the client needs to be determined. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. b. The client states, "I'm feeling a bit nervous today." a. Shakes the soiled linen to remove any toilet paper remnants 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. Remember, pick the killer answer first! A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. The spouse can rescind the Advance Directive if the client becomes unresponsive. 2. Assessing this client and titrating the diltiazem requires the skills of an RN. 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. Occupational therapist A charge nurse is making client care assignments. 1. Clients over the age of 65 must have a saline lock according to facility policy However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. A charge nurse is observing a group of newly licensed nurses. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. Understanding the charge nurse's role in staffing 4. a. Which of the following client statements should indicate to the nurse the need for additional teaching? & 6. Turn on local news for up-to-date information on the train derailment. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Involve the client in their plan of care. A nurse just back from maternity leave. What client should the nurse assess first? b. An increased temperature will have a direct effect on the brain's metabolism and function. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Alcoholic Anonymous Return any fresh linen not used for a client to the linen supply area Tenderness over the symphysis pubis b. c. Hallucinations at the onset of sleep, 65. "The client is weak on the right side, so please assist the client with dressing . Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Where on the body is each type of skin found? a. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Provides day to day direction and supervision to assigned direct patient care staff. 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. 4. -Review a low-sodium diet for a client who has HTN What was the rationale for this plan? Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. 3. Document what the nurse believes was the cause of the ulcer development A cardiac step down unit has requested float staff because of multiple impending admissions. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 2. The client is reporting anxiety, discomfort, and a feeling of bloating. b. I will bear the weight of my body on my hands Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. 208 d. Message, 67. 4. Accept assignment, documenting personal concerns regarding work conditions. Which action should the nurse interrupt the UAP from performing? Which of the following actions should the nurse take? 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. Incorrect: The nurse is responsible for evaluating a client. c. 214 4. Which of the following actions should this nurse take? 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. 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. b. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. This is an appropriate prescription. and 16 g of fat. The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. c. Review a low-sodium diet for the client who has hypertension The nurse should perform which of the following activities in this space? Assist a client to ambulate using a gait belt. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. Incorrect: This response overlooks a potentially severe problem. Vital sign measurement Select all that apply The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. Provide an adaptive feeding device for the client Aplastic anemia is a rare but serious condition. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. Which client can be assigned to the LPN? Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. The charge nurse on the postpartum unit is making assignments. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Left upper forearm Underline the adjective clause in each sentence. One important aspect is encouraging the flow of ideas between management and staff members. 6. 1. Tenderness over the symphysis pubis Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Incorrect: The RN is responsible for collecting data. Which of the following actions should the nurse take? which client would be an appropriate care assignment for this lpn? a. 2. Which of the following statements should the nurse identify as an indication the client needs further teaching? A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. c. Helping the client into the shower 4. During exacerbation, the client will have many diarrhea stools. Show client who has conjunctivitis how to clean the eyes. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. d. Anger, b. This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. b. I'll use the cleansing wipes from the front to back Monitor for GI upset 30 minutes after meals. 4. These are appropriate tasks for an UAP to complete. Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand).