a. c. I suggest you talk with a mental health counselor about your concerns Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Nothing life threatening, but an assessment needs to be made regarding the ulcer. 5. Narrative interaction d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Right forearm Client one day post kidney transplant. What client should the nurse assess first? These individuals are selected by the charge nurse, and do not have to be nurses. Administering IV pain medication to a two day post op client. b. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 4. The nurse has just completed a 12 hour shift. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Which of the following actions should the nurse take? Which of the following responses should the nurse make? a. Which clients could be assigned to an LPN? 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. Select all that apply An adolescent client post appendectomy reporting pain. 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. Give magnesium citrate 296 mL at 3 PM today. 3. a. e. Dysuria, 49. 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. d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. Perform catheterization when you recognize the urge to void Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Aplastic anemia is a rare but serious condition. Which of the following communication techniques should the nurse use during this phase? b. 1. d. Complete an incident report, 70. The client is getting better. (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 Schedule visiting times in two-hour increments so clients are not overwhelmed. Call the family of a client suffering from dementia to discuss long term care placement. The charge nurse's best response is to first obtain the needed information to make the best decision. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? b. 2. A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. b. 2. A nurse who is breastfeeding her 4 month old. b. A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. 2. 2. a. Bathtub with rails a. A charge nurse is making client care assignments. Based on this information,what should the nurse do? a. I'll apply ankle to my ankle today and tomorrow b. I will call the doctor and get the prescription An adult (18 years or older) can create an advanced directive. What information should the nurse include? Ask client if they are eating small, frequent meals. If a sentence is already correct, write CCC. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. 4. 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. Client prescribed antibiotics for cystitis. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. Tenderness over the symphysis pubis The nurse who made the medication error should take which of the following actions first? Discuss the issue with the leader of the "best practices" committee. d. Decreased calcium excretion, c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown), 27. For which of the following actions should the nurse intervene? d. Determine if the client uses hearing aids, b. A cardiac step down unit has requested float staff because of multiple impending admissions. The nursing supervisor may be able to assist with client care until another nurse can come in to work. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. c. Measurement of residual urine after urination d. Discussing intake and output Measure urine output when client voids. c. Distended bladder 1. a. 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. The cause of the fall may be cardiac, but the question does not indicate this. This is an elderly client who is a new admit. a. Symbolic communication Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? Transfer essential medical record to the receiving facility. A nurse is caring for a client whose partner asks to speak with the nurse. Assign more daily tasks to the UAP. There are a total of 10 adult clients. Injuries from a motor-vehicle accident can be life threatening. b. Compartment syndrome could be developing which can impede circulation and cause nerve damage. Determining the client's length of stay Identify and assess each incoming client. Provides day to day direction and supervision to assigneddirect patient care staff . Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. 1. 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. Which of the following instructions should the nurse include? 4. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. Which of the following statements should the nurse identify as an indication that the client needs further instruction? 3. A nurse is adhering to standard precautions while caring for a group of clients. Ask for any staff objections to rearranging work hours. Evaluate pain relief after narcotic administration. Incorrect: No, the monitoring is too specific for the med-surg nurse. There may be a good reason that the tray was not served. Initiate oxygen and IV lines as needed. Which of the following methods should the nurse plan to use? Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . 1. c. Contact This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. 4. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. c. Environment c. Malpractice Most of the following sentences contain errors in the use of modifiers and comparisons. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Female client stating she has been raped. There will likely be both physical and emotional injury that needs attention, which places this client third. 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? d. 216, 22. a. Shakes the soiled linen to remove any toilet paper remnants 4. Notify the nursing supervisor of the situation. A nurse is planning to discharge a client who has quadriplegia to his home. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. 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. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. 4. a. c. Changing a dressing 2. 3. We do not know the extent of her injuries based on what the option tells us. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. d. Go to employee health services, b. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. b. 2. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. d. Assault, b. 4. 4. 2. Client scheduled for a dressing change to foot ulcer. A nurse is assessing a client who has narcolepsy. 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 A nurse caring for a client is using active listening skills. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. -Review a low-sodium diet for a client who has HTN Pain In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. The client reports constipation for 4 days which may be an indication of worse problems. Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. 3. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Which action should the nurse interrupt the UAP from performing? But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. The nurse could definitely be part of the committee. What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? d. Sleep apnea d. The nurse has already considered alternatives to restraints, a. b. (Select all that apply.). a. A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. 1. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. In which situation should the nurse consult the client's advanced directive? The nurse would then start the 24 hour urine once the 1st void has been discarded. Notify the primary healthcare provider. which client would be an appropriate care assignment for this lpn? Correct: Disconnecting NG tube suction is an appropriate task for the UAP. e. The urge to move the legs when trying to sleep, 66. Remind the client to tell the nurse when he has to urinate When the licensed person cannot determine this, the task should not be delegated. When a family member asks how respite care can help, which of the following responses should the nurse provide? Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Which of the following physiological responses to prolonged immobility should the nurse expect? A nurse asks a client how he is feeling. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Which of the following actions should the nurse take? Serve milk products separately from meals The nurse has received the change-of-shift report. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. Which of the following actions should the nurse include in the plan? A person can be designated to make medical decision in the event the client cannot. b. I'm so sorry to hear about this Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a The third client would be the one needing a dressing change. a. The stem does not indicate any loss of neurological function resulting from the seizure activity. Review a low-sodium diet for a client who has hypertension. Client to receive dietary education. b. c. Take the client to the bathroom every 2 hr However, each unit must have one designated representative to send to the command center, when requested, to receive and then relay, pertinent information back to the unit. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. Notify the charge nurse of the observations. b. a. I will begin 48 hr before the client's discharge a. The client states, "I am so nervous about what the doctor might find during the test." The nurse on a large surgical unit needs to evaluate several clients returning from procedures. 6. 3. Which of the following interventions should the nurse include? This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. c. Visual observation for nonverbal signs of pain Drag and Drop the items from one box to the other. 2. Changing a colostomy bag. The client says, "go away, no one can help me." 4. Which of the following statements should the nurse make? d. Put the side rails up and tell the client to call the nurse before voiding, d. Two nurses using a friction-reducing device (reduces the risk of injury to the nurses and to the client; nurses can use a draw sheet as a friction-reducing device), 38. Review the action of insulin therapy 1. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. b. Ask the client to perform a return demonstration of insulin injection A nurse is admitting a client from a long-term care facility. Client with a T-5 spinal cord injury beginning rehabilitation therapy. This client can wait until the others are treated. b. Ask the float nurse, "Have you been drinking?" 3. Irrigate a client's ear canal. Discuss the assignment with another LPN. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. This can prevent harm to client's. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. c. The emphasis is on the client's complete recovery from the illness or injury b. Determine which personnel could be sent to the command center. The RN with 2 weeks' experience on the postpartum unit. During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate? 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. Request a prescription for a medication to ease the client's anxiety The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Use the tablet's packaging to pick it up from the counter A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Which of the following actions is the nurse's priority? Pick up the tray and tell the UAP that they didn't do a good job. Which of the following statements by the student indicates understanding of the discussion? Report of feeling pressure This client is not the nurse's first priority. Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Incorrect: Moistening the dentures will ease insertion. a. c. I will cover the catheter so he cannot see it b. (Select all that apply.) d. I have a set of my brothers' crutches in the basement I can also use, a. c. Include intact skin at the wound edges in the culture c. Hallucinations at the onset of sleep Performing passive range of motion (ROM) on the client with right sided paralysis. 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. Client with ureterolithiasis who requires frequent PRN pain medication. Following the teaching, the nurse asks the client to describe one physical effect. b. Patient safety must remain the priority. A nurse is having difficulty caring for a client due to variables affecting the communication process. d. Providing information, a. Try different methods of oral care on unresponsive clients to see what works best. This is the most stable of the four clients which places this client last to be seen. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? The client post PEG placement is stable. Which of the following responses should the nurse make? 3. 5. Read all the current literature related to oral care on unresponsive clients. 3. c. Hold an object away from her body as she lifts it 4. 4. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? b. 3. Incorrect: The charge nurse does not have to assess every client. a. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. Based on these findings, to which of the following providers should the nurse request a referral for the client? 4. 3. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. 3. 3. A list of current medications is sent to the facility. d. Respite care is a continuation of psychological support after a family member dies. The nurse has another priority. Which of the following tasks should the nurse delegate to assistive personnel (AP)? c. I will make sure my visitors smoke outside d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. a. The nurse should not be assigned to provide care if impairment is suspected. c. Tie linen bags securely at the top Include any relevant statements the client made about the ulcer Wears a gown when entering the room of a client who requires contact precautions The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Battery Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Which of the following responses should the nurse provide? Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. 1. A nurse is caring for a client within the intimate zone of the client's personal space. So, the UAP can assist a client to brush and floss teeth. 3. Correct: This group of clients is primarily med surgical. d. Explain oral hygiene to a client receiving chemo d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Call the client's provider A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. b. I can detect the presence of carbon monoxide by a metallic odor d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. 1. a. 2. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. c. Leave a nightlight on in the client's room Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? a. Clarification 2. c. Initiate a liquid diet for the client 1. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. 1. A client with a fractured right humerus who reports the cast is too tight. 4. c. Blood-tinged urine A charge nurse is making client care assignments. Checking capillary refill beneath the client's fingernail UAPs can assist with elimination and are taught how to measure output. Anyone over age 18 can have an Advanced directive. Which region of the tRNA pairs with mRNA? Elevating the head of the bed 30- 40 for the client post thoracotomy Who should the nurse see first? Select all that apply There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. American Sickle Cell Anemia Association 1. Administering 3 g/hr IV of morphine would be extremely dangerous. Incorrect: This response overlooks a potentially severe problem. The nurse caring for the client at the time of death requests organ donation 4. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? The nurse has been assigned four clients. 3. The nurse is using which level of communication at this time? e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. What is the best first action for the nurse to take in order to achieve this goal? 3. Incorrect: The nurse is responsible for monitoring a client. c. Review a low-sodium diet for the client who has hypertension 4. Refuse the delegated intervention. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. Select all that apply. a. Risperidone .5 mg PO daily What was the hint? The nurse is reviewing some clients' prescriptions. Involve the client in their plan of care. c. Hand-off technique 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 nurse is assessing a client who is experiencing prostatic hypertrophy. 1., 2., & 5. a. e. Feed a client who had a stroke 3 months ago, 32. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. c. I will complete the smoking cessation program I started Hanging a new bag of total parenteral nutrition (TPN). A two-hour limit on visits discourages quality time. Allow families unlimited visitation around the clock to meet their schedules. What is the best response by the charge nurse? Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. Select all that apply a. The surgeon initially prescribes a clear liquid diet. Cystogram reporting burning on urination. Which of the following actions should the nurse include in the plan? a. A nurse is preparing a sterile field. 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. Charge nurses have integral roles in healthcare organizations. a. I will wear gloves when removing food from the freezer _____The house that we lived in for nine years has been sold. 1. Autonomy vs shame and doubt CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. This includes medication enemas. 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. c. Lock the medication in a room and finish preparing it after returning from the emergency 7. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Lumbar puncture reporting a headache. a. I'll provide more stimulation in his environment 1. 4. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". Photo comes from the Greek word for light. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. The charge nurse knows what client would be most appropriate for this LPN? Which task would be appropriate for the nurse to assign to an LPN/VN? c. Provide the client with a diet high in protein a. a. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Draining the colostomy bag on a client with diarrhea. Elderly client who fell and fractured the left femoral neck. c. Open the right flap with the left hand A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. 4. An increased temperature will have a direct effect on the brain's metabolism and function. It also helps the client deal with issues that are important to him), 19. Which of the following actions should the nurse take? a. one of the licensed practical nurses Get the answers you need, now! "The client is weak on the right side, so please assist the client with dressing . Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy.