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The third client that should be sent back for treatment is the female client stating she has been raped. Assist ait to ambulate using a gait belt. c. Hallucinations at the onset of sleep 1. a. A charge nurse is making client care assignments. b. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. 2. 4. A nurse is caring for a client who has a wound infection. a. I'll sit with my knees lower than my hips A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. a. b. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter The nurse is using which level of communication at this time? 1. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Teaching insulin self administration to a diabetic client. 1. Each ROM movement should be repeated 5 times during the session. The nurse could definitely be part of the committee. Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. The charge nurse on the postpartum unit is making assignments. b. Take several shallow breaths during the procedure 1. But the client does need to be assessed prior to the client with Crohn's disease who is improving. b. 4. Decide which choice fits best in the blank. c. Environment Start MgSO4 at 3g/hr IV A high concentration of carbon monoxide can cause death d. Voided 30 mL frequently NUR 204 ATI Management of Care Ch. 1-9 Flashcards | Quizlet A nurse receives a client care assignment from the charge nurse that he believes is unfair. 1. Correct: Did you notice the hint? Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? c. I will make sure my visitors smoke outside Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. Review a low-sodium diet for a client with hypertension. Check environment for potential safety hazards. b. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). 3. There may be a good reason that the tray was not served. Teaching is not in the role of the LPN and therefore, this client would need to be assigned to the RN, not the LPN, for the teaching needs of the client. Draining the colostomy bag on a client with diarrhea. 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. c. Can you tell me why you chose me? This task cannot be delegated to the LPN/LVN. The area surrounding the insertion site feels warm to the touch 2. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. The client's self-report of pain severity, 88. Everything will be okay A medical-surgical LPN has been sent to a short-staffed pediatric unit. A nurse receives a client care assignment from the charge nurse that he believes is unfair. An adolescent client post appendectomy reporting pain. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. 3. d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. Which of the following activities should the nurse perform in this zone? Channel Nurse-patient assignments help coordinate daily unit activities, matching nurses with patients to meet unit and patient needs for a specific length of time. Remind the client to tell the nurse when he has to urinate Tenderness over the symphysis pubis b. Urinary frequency for several days 1. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. 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. 1. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. 1. 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. Explain to the RN that all the nurses have the same number of clients. Which of the following findings should the nurse expect? Providing hygiene care to a client who is HIV positive When staff do not feel vested in any new process, there is a sense of underappreciation. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Wrapping the dentures in tissue while the client sleeps d. Go to employee health services, b. 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 3. Ask the RN why the assignment is too heavy. Showing disapproval 4. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. It is quicker to administer medications intravenously in the hospital All these clients have a GI problem. b. Verbalize understanding of how the client feels e. Feed a client who had a stroke 3 months ago, 32. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Tenderness over the symphysis pubis 3. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. b. If you give the magnesium citrate, which is a laxative, what will happen? For which of the following actions should the nurse intervene? A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. 1) Bathe a client who had an amputation 2 days ago. Nothing life threatening, but an assessment needs to be made regarding the ulcer. 1. c. Explain the risks and benefits of the procedure A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. a. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures 2. Printable Nursing Brain SheetPrintable Nursing - soyu.caritaselda.es b. I can detect the presence of carbon monoxide by a metallic odor 3. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. 5. Which of the following indications should the nurse include? Incorrect: The RN is responsible for assessment and evaluation of clients. 3. 3. 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. Remove all metal necklaces Which of the following statements should the preceptor make? 1. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 1. d. Highly concentrated urine, 91. Serve food that have a hot/cold balance a. M4 Client Care Assignment.pdf - Making Client Care After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. Client eating a simple-carb snack due to weakness. a. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. 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. 212 a. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Client reporting epigastric pain and nausea after eating. Notify clients that the disaster plan has been put into effect. What action should the nurse take after mistakenly administering the wrong medication? Incorrect: No, the monitoring is too specific for the med-surg nurse. The nurse cannot allow the UAP to perform advanced tasks. The nurse chooses to confront the client. a charge nurse is making client care assignments for the day. which Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. Report the incident to the charge nurse The nurse has another priority. 1. Client #5 -It is considered within the scope of practice for an LPN/LVN to monitor a transfusion of a blood product. The key word in the stem is first. 3. Place the client in a lateral position Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? A client with fibromyalgia reporting generalized pain of 7 out of 10. Which of the following instructions should the nurse include? This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. 1. 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. Review the action of insulin therapy Reach around the pack and open the top flap away from the body, 53. 3. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. Accept assignment, documenting personal concerns regarding work conditions. b. As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. There is a possibility that a hypothermia blanket may be prescribed. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. Female client stating she has been raped. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. 4. This would be an acceptable task to assign to the UAP. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? The supervisor can only send one LPN/LVN to the floor. D. 3. 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. Twist at the waist when she moves an object to one side _____The house that we lived in for nine years has been sold. he charge nurse is making client care assignments for the evening shift b. 3. This is a task that can be delegated to the LPN/LVN. Select all that apply. 3. A client who is disoriented and awaiting transfer to a long-term care facility. a. 4. c. Changing a dressing The provider must renew a restraint prescription every 8 hr. a. Documentation of what occurred, and the client's assessment is required in the nurse's notes. 2. Thoracentesis reporting shortness of breath. b. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Client reporting a headache and has a fruity breath. 1. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Irrigate a client's ear canal. Place the client in low Fowler's position b. 2. Lisinopril 20.0 mg PO daily The nurse should use close-ended questions when assessing which of the following factors? Notify the primary healthcare provider of transfer completion. d. Left forearm, b. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. a. I will begin 48 hr before the client's discharge What would the approximate meaning of photoelectric be, based on these root words? Besides yourself, there are the following staff: Your unit has 12 beds. The client can indicate desire for Do Not Resuscitate (DNR). Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Call the client's provider c. Rephrase statements the client does not hear d. What have you done in the past to cope with this issue? If the client is unstable, the nurse would retain the role of measuring the vital signs. 5. d. Social conversation, a. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. Encourage clients and families to develop mutually appropriate visitation times. Select all that apply There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. A nurse is caring for a client who is immobile. Announce the new changes at the monthly staff meeting. Try different methods of oral care on unresponsive clients to see what works best. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. d. I will place a bath seat in my shower to use when I bathe, b. The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. Notify the board of nursing (BON) that the float nurse is an alcoholic. a. Gloves 3. A nurse caring for a client is using active listening skills. b. b. I will keep the fluorescent ceiling light on in my room at night a. The charge nurse should notify the nursing supervisor who will seek additional staff. The stem does not indicate any loss of neurological function resulting from the seizure activity. a. Thus, the tasks involve successful management of the charge nurse's responsibilities. (Select all that apply.) Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. 2. c. Hallucinations at the onset of sleep, 65. b. 3. 3. NUR 112 Practice Assessment Flashcards | Quizlet What was the hint? Discussing a client's surgical procedure with the nurse manager b. eminent 3. 4. Reporting laboratory findings to a member of the client's family A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. The infusion rate has stopped but the tubing is not kinked b. 4. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? A cardiac step down unit has requested float staff because of multiple impending admissions. Performing passive range of motion (ROM) on the client with right sided paralysis. The below statement corresponds to a numbered sentence in the passage. 4. 4. Which of the following responses should the nurse make? The client should be assessed first to rule out respiratory difficulty and hemorrhage. The nurse has just completed a 12 hour shift. A nurse is assessing a client who has narcolepsy.