The nurse is using which level of communication at this time? American Sickle Cell Anemia Association A charge nurse is making client care assignments. Incorrect: It is important to hear what the nurse is saying and not to dismiss the request by refusing to reassign the clients. If you give the magnesium citrate, which is a laxative, what will happen? Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Talk to each nurse about concerns related to assigned clients. The nurse should not be assigned to provide care if impairment is suspected. Irrigate a client's ear canal. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Remember airway, breathing and circulation (ABCs). Which of the following actions should the nurse take prior to administering the tube feeding? This service focuses on teaching the primary caregiver to meet the client's needs 1. When asking the client about his receptiveness to the transfer a. Auscultate breath should at least ever 2 hr Send a day's worth of medications with the client to the receiving facility. Education Incorrect: Moistening the dentures will ease insertion. 3. 2. _________________ (magnanimous), a. generous c. The restraints should promote the client's safety and prevent injuries Which of the following indications should the nurse include? This client is not the nurse's first priority. 4. 2. a. I'll apply ankle to my ankle today and tomorrow Notify the board of nursing (BON) that the float nurse is an alcoholic. When a family member asks how respite care can help, which of the following responses should the nurse provide? Lumbar puncture reporting a headache. 1. leadership management of care nurse on unit is providing care for group of clients. 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. b. A post-cardiac catheterization needing assistance with bedpan. Incorrect: This response overlooks a potentially severe problem. b. d. I have a set of my brothers' crutches in the basement I can also use, a. The nurse is using which level of communication at this time? e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. 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. However, there are some basic points which are standard among all facilities. 2. a. Two hours . 2. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. a. -Review a low-sodium diet for a client who has HTN Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? 1. The reason for the UAP not feeding the client needs to be determined. b. 3. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. A nurse is preparing to obtain a blood specimen from a client by venipuncture. 4. 2. A client on a surgical unit frequently quarrels with the staff. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. The nurse does not know the skills of the new UAP. Incorrect: The nurse retains the responsibility for the delegated task. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. a. A nurse instructs a female client about collecting a midstream urine sample. A client has been admitted with folic acid deficiency anemia. Bargaining Which nursing intervention should the charge nurse implement? Hanging a new bag of total parenteral nutrition (TPN). Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. b. Review a low-sodium diet for a client who has hypertension. c. Review a low-sodium diet for the client who has hypertension Which of the following tasks should the charge nurse reassign to a licensed nurse? Request a prescription for a medication to ease the client's anxiety 1. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a A nurse is caring for a client who has a mental health disorder. The client then states, "I have changed my mind and do not want to have the procedure done." b. I will bear the weight of my body on my hands This client needs ongoing monitoring which is within the scope of practice for the LPN. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. Which of the following should the nurse identify as an interpersonal variable? Include any relevant statements the client made about the ulcer, 64. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. The RN with 8 years' experience in the Intensive Care Unit. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Which of the following info should the nurse include? a. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. 1. Teaching insulin self administration to a diabetic client. Read all the current literature related to oral care on unresponsive clients. Tenderness over the symphysis pubis c. Can you tell me why you chose me? Serve food that have a hot/cold balance Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Assist a client to ambulate using a gait belt. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. Which of the following is the priority action by the nurse? Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 2. Obtain a client's consent a. Channel 1. c. Shivering 4. 3. It is crucial that the oncoming staff have an opportunity to voice any concerns regarding assignments and clarify any information provided.This proper exchange of information and concerns helps to ensure the safety of clients, provides continuity of care, and possibly prevents problems that might arise if these concerns had not been addressed. The assignment process requires constant evaluation and reevaluation of information and priorities. Provide positive feedback to the UAP. 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. It is not a routine task. d. Perception "Please explain what you mean by the word 'nervous'.". 1. The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. b. a. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. (Select all that apply.) Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Complete blockage of the large intestine. d. I shouldn't advice you about what is ultimately a personal decision, b. It also helps the client deal with issues that are important to him), 19. 2. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Which of the following responses should the nurse provide? Which of the following actions should the nurse take? A nurse is caring for a client who is postoperative. b. The nurse would then start the 24 hour urine once the 1st void has been discarded. 1. 1. - Assisting a client to ambulate using a gait belt. d. Discussing intake and output This is outside the scope of practice for the LPN/LVN. d. Providing information, a. c. Providing anticipatory guidance to a client in crisis b. The client's self-report of pain severity, 88. a. Triage and assign color-coded tags to each client. Which of the following interventions should the nurse include? The client's self-report of pain severity Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Teaching insulin self administration cannot be delegated to the LPN. The client receives home health care and spends most of his day in a reclining chair. Protective 2. A nurse is assessing a client at a follow-up clinic for acute low back pain. 2. Sudden attacks of sleep Incorrect: This group of clients needs specialized care. & 6. 3. The option does not say the client is terminal, in a vegetative state, or in a coma. Licenced practical nurses are a little less educated than registered nurses. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? 2. 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. (Select all that apply) a. 4. 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. d. Services are centered in long-term care facilities, a. Thus, the tasks involve successful management of the charge nurse's responsibilities. Although this will require assessment, this client is not the priority at this time. The LPN can monitor the wound and provide care to the PEG insertion site. A charge nurse is planning client activities for the day. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. It happened so long ago - just get over it!" Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. They have found my address and are coming for my family!" A client with atrial fibrillation currently on a diltiazem drip. The charge nurse is developing patient care assignments for the evening shift and needs to assign clients to a licensed practical nurse/licensed vocational nurse (LPN/LVN) and a certified nursing assistant (CNA). A charge nurse is making assignments for an oncoming shift. Which of the following info should the nurse include? Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47. The body needs vitamin B12 to make red blood cells. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. a. c. Explore the client's feelings about dietary modifications b. (Select all that apply.) It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). Describe the types of machining operations that can be performed on a lathe. Incorrect: The concern here is the client being fed their meal. Checking capillary refill beneath the client's fingernail Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. 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. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. 3. A nurse is completing discharge teaching with a client. What is the appropriate assignment? B. 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. We see that the temperature is already elevated, which makes us worry that infection is present. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. Assign a nursing assistant to help the client with self-care activities. Incorrect: This again is assessment which is the role of the RN only. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. Which of the following physiological responses to prolonged immobility should the nurse expect? Which action by an unlicensed nursing assistant would require the nurse to intervene? b. This could cause a medical emergency. These individuals are selected by the charge nurse, and do not have to be nurses. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day c. I will make sure my visitors smoke outside Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. Based on the information provided in report, which client condition should be the nurse's priority? Accept assignment, documenting personal concerns regarding work conditions. Gather and apply dressings to open wounds. 4. 4. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Which of the following instructions should the nurse include? Which of the following instructions should the nurse include? Select all that apply. a. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. _____The house that we lived in for nine years has been sold. This should not be delegated to the LPN/LVN. What options would be appropriate for the nurse to take? A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Everything will be okay These are appropriate tasks for an UAP to complete. This service began with the client's admission to the hospital, 18. 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? A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Explain oral hygiene to a client receiving chemotherapy Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Incorrect: The client does need to have food; however, there is another action that should be performed first. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Each state BON differs in that also some have treatment programs they administer themselves. There is a trailing zero after the prescribed dose.

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