Which region of the tRNA pairs with mRNA? 4. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. 1. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Aplastic Anemia Support Group. This stage involves constructive efforts on the part of the group members d. Services are centered in long-term care facilities, a. a. 2. This stage is when testing occurs to identify boundaries of interpersonal behaviors Notify the charge nurse of the observations. (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. c. Discard the tablet and obtain another dose of medication Temporary urinary retention (common for clients to develop after removal), 90. Comatose client with end stage chronic obstructive pulmonary disease. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. A nurse enters an older adult client's room to insert a saline lock. Client to receive dietary education. Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. c. Use intermittent eye contact Determining the client's length of stay The LPN/LVN can reinforce teaching. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures 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. 2. 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. b. A nurse is having difficulty caring for a client due to variables affecting the communication process. the nurse responds, "don't worry, no one will harm your family." c. I suggest you talk with a mental health counselor about your concerns 3. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A client with epilepsy reporting an odd smell in the room. d. Providing information, a. This client will also need a lot of education regarding anti-rejection medications. Which of the following actions by the nurse is considered an indirect nursing care activity? Pick up the tray and tell the UAP that they didn't do a good job. The other options may be correct but are not the best first action. Underline the adjective clause in each sentence. 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. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. 3. Encourage client to express grief related to loss of independence. Client with chronic emphysema experiencing mild shortness of breath. 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. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. a. Which of the following items should the nurse offer the client? The RN requests reassigning at least one of the clients to another nurse. During exacerbation, the client will have many diarrhea stools. Ask the charge nurse to evaluate the intervention. B. This client is stable and predictable. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. 6. b. Ambulating a client who is 2 days post vaginal hysterectomy Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. 1. Education b. 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. Select all that apply. Increased insulin production b. 1. The healthcare team should recognize the client as the center of the team. Assess personal level of fatigue prior to making a decision regarding accepting or refusing assignment. A nurse is engaging in relationship counseling with a male client. c. Notify the nurse manager The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). 2. "The client is weak on the right side, so please assist the client with dressing . c. I will inspect my crutches everyday for signs of wear Currently, your census is 11, with one empty bed. Discuss the assignment with another LPN. 1., 2., 3., & 4. 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. b. I will begin once the client's discharge order is written d. Do you think crying will help? Two hours . Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Hanging a new bag of total parenteral nutrition (TPN). 1. The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. Assist a client to ambulate using a gait belt c. Changing a dressing 1. b. Summarization Explain administration is demanding a decreased overtime. Which of the following actions should the nurse take prior to administering the tube feeding? b. 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 findings associated with urinary retention should the nurse expect? Feedback Reach around the pack and open the top flap away from the body, 53. A nurse is assessing a client who has narcolepsy. a. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) d. Voided 30 mL frequently Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Which of the following nontherapeutic communication techniques is the nurse using? a. 2. The client must understand the need for restraints The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. a. Handoff and Nursing Report Sheet. Accept assignment, documenting personal concerns regarding work conditions. An LPN/VN has been floated to the emergency room following a chemical plant explosion. Nurses dependent on drugs or alcohol can harm clients. a. When determining if the client is eating a well-balanced diet The RN with 8 years' experience in the Intensive Care Unit. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. b. 3. c. The client's culture Teach the UAP to change surgical dressings. Prepare a list of clients who could quickly be discharged or transferred. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? 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. 2. A charge nurse is observing a group of newly licensed nurses. Select all that apply Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. A client has been admitted with folic acid deficiency anemia. Incorrect: This group of clients needs specific teaching. Correct: Did you notice the hint? Client prescribed antibiotics for cystitis. Yes! Notify clients that the disaster plan has been put into effect. Which actions should be instituted by each unit's charge nurse? 4. b. Numbness b. 2. c. Review another client's similar surgical experience b. I will bear the weight of my body on my hands The charge nurse should notify the nursing supervisor who will seek additional staff. The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. d. When asking if the client took his medications this morning, 82. 1. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? Incorrect: It is out of the UAP's scope of practice to administer medication. (Select all that apply.) Which of the following actions should the nurse take? The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. d. Lean back in the chair, b. 2. The nurse has received the change-of-shift report. Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. Sit side-by-side with the client Incorrect. No! d. Respite care is a continuation of psychological support after a family member dies. This situation is considered an external disaster which means the hospital will be expecting multiple victims. 2. 4. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. A nurse has completed an informed consent form with a client. d. Proceed with the preparation of the patient's surgical procedure, 15. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 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 2. To which of the following rooms should the nurse assign the client? Most of the following sentences contain errors in the use of modifiers and comparisons. 4. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. The nurse asks why the client needs to know this. A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? Document what the nurse believes was the cause of the ulcer development 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. A nurse is preparing an education presentation about organ donation for a group of newly licensed nurses. Removing the client's dentures Which of the following statements should the nurse identify as an indication the client needs further teaching? Remember, pick the killer answer first! Thoracentesis reporting shortness of breath. Which of the following actions should the nurse take? c. Initiate a liquid diet for the client 1. Incorrect: This response overlooks a potentially severe problem. d. They disclose more personal information, a. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Elderly client admitted 30 minutes ago with reports of constipation for four days. d. Let's wait until tonight to see if he continues his behavior, 63. a. Teaching insulin self administration cannot be delegated to the LPN. 4. The cause of the fall may be cardiac, but the question does not indicate this. Placing a washcloth in the bathroom sink prior to cleaning. Everyone knows there are others who can chair this committee better than me A nurse is developing a plan of care for a client who does not speak the same language as the nurse. This client is at a high risk of infection. This is a diabetic clinic. He charge nurse is making client care assignments for the evening shift. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. 4. 3. Administering 3 g/hr IV of morphine would be extremely dangerous. 3. A nurse is preparing to move a client who is only partially able to assist up in a bed. A nurse is caring for a client who is postoperative following an appendectomy. Donning gloves and using a gauze pad to grasp and remove dentures Which of the following info should the nurse include? b. c. I'll bear weight on my ankle for 10 minutes every hour a. 3. Which of the following is the priority action by the nurse? On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. 5. 1., 2., 3., & 4. Make referrals to community services. Select all that apply. Which of the following actions is the nurse's priority? Triage and assign color-coded tags to each client. d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. Perform the Heimlich maneuver Monitor client for pain while assisting with ambulation. The nurse could definitely be part of the committee. b. Assess the client Correct: An LPN should be assigned clients with predictable outcomes. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Which of the following statements should the nurse identify as an indication that the client needs further teaching? This service focuses on teaching the primary caregiver to meet the client's needs b. The nurse is caring for four clients. Vital sign measurement Removing the client's dentures d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. _____The house that we lived in for nine years has been sold. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. c. The client was restless and trying to get out of the bed all evening 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. _________________ (magnanimous), a. generous Client diagnosed with inoperative brain tumor who is confused. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. So, now you must decide which of these high priority clients should be seen in what order. Correct: The UAP can remind the client to do something that has already been taught by the nurse. However, providing care for missing teeth would also be within the LPN scope of practice. 4. a. I will wear gloves when removing food from the freezer Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. c. The emphasis is on the client's complete recovery from the illness or injury Moistening the dentures prior to inserting them Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? Turning off continuous tube feeding to reposition a client, then turning the feeding back on. (Select all that apply.). Prior to turning feeding back on, tube placement needs to be verified. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. which client would be an appropriate care assignment for this lpn? 1. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. a. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Determine caregiver's stress level and coping strategies. What interventions can the nurse delegate to the LPN/VN? a. Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. d. Mask, 83. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 3. Documentation is a communication tool for the interprofessional health care team. b. Confrontation should occur in the presence of a charge nurse or supervisor. 5. The nurse should assess the client for which of the following expected outcomes after catheter removal? 5. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. 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. 4. Twist at the waist when she moves an object to one side A nurse is caring for a client who is about to have a colonoscopy. 3. What is the major histological difference between thick and thin skin? A nurse is discussing the norming stage of the group development process with a student nurse. b. The first vital sign check was performed by the nurse. Which action should the nurse interrupt the UAP from performing? Incorrect: This is not completely practical for everyone. Correct. 2. The LPN can monitor the wound and provide care to the PEG insertion site. A nurse is admitting a client from a long-term care facility. d. Custard 1. a. The best practice committee utilizes current research in their recommendations. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. c. Leave a nightlight on in the client's room 4. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. This client needs careful monitoring and specialized care. 1. Respite care provides holistic support and care for a client who is terminally ill There may be a good reason that the tray was not served. Check environment for potential safety hazards. 1. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. What was the rationale for this plan? 1. 2. Providing a passive response A nurse is prioritizing care for two clients at the start of the shift. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. 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. The nurse is using which of the following therapeutic communication techniques? There is a trailing zero after the prescribed dose. This includes medication enemas. 4., & 5. 1. 3. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. c. I will place an area rug at the entry of my bathroom c. Industry vs inferiority 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. d. I decline this opportunity at this time, b. To confirm the placement of the NG tube 1. 4. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. . a. 1. a. A charge nurse is making assignments for an oncoming shift. Select all that apply Which of the following instructions should the nurse include? Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. A client with diabetes admitted for debridement of a foot ulcer. Request a prescription for a medication to ease the client's anxiety b. b. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). e. The urge to move the legs when trying to sleep, 66. Evaluate client's safety risk factors. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. 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. Provides day to day direction and supervision to assigned direct patient care staff. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. Denial A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. d. Remove and reinsert the NG tube, a. c. They tend to use more verbal communication 3. (Select all that apply.) A nurse is adhering to standard precautions while caring for a group of clients. 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. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Return any fresh linen not used for a client to the linen supply area Sudden attacks of sleep 3. The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. When staff do not feel vested in any new process, there is a sense of underappreciation. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. butter, which contain 16 g of protein, 7 g of carbohydrates, Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. 3. 1. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Alert all off-duty personnel to stand by in case of call- in. Schedule visiting times in two-hour increments so clients are not overwhelmed. a. 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. Which of the following methods should the nurse plan to use? Assist client to brush and floss teeth. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Decreased RBC production 208 As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. 4. Administer tap water enemas until clear at 6 AM. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? 10. Gown (Select all that apply.). Disconnect client's nasogastric (NG) tube suction to allow ambulation. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? Which of the following instructions should the nurse give to the client prior to the procedure? a. The nurse should do this when repositioning is needed. Incorrect: Informing is the same thing as teaching. 4. Include any relevant statements the client made about the ulcer, 64. 1. d. Discussing intake and output This can prevent harm to client's. This service began with the client's admission to the hospital, 18. 3. c. To determine the client's electrolyte balance 1. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Start MgSO4 at 3g/hr IV b. b. Dons gloves to empty a urinary drainage device So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. Select all that apply. 1. Electric cords behind the furnitrure For which of the following tasks should the nurse wear protective eye equipment. Remind the client to tell the nurse when he has to urinate a. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. Ask the float nurse, "Have you been drinking?" Which of the following client statements should indicate to the nurse the need for additional teaching? c. Irrigating a client's abdominal wound Client reporting epigastric pain and nausea after eating. An increased temperature will have a direct effect on the brain's metabolism and function. Feed the client after warming the food. Refuse the assignment, being prepared for disciplinary action. Pernicious Anemia Society Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. b. Negligence 1. These are appropriate tasks for an UAP to complete. 5. 2. Involve the client in their plan of care. The expected standard of care was strict bed rest), 96. b. Discuss the issue with the leader of the "best practices" committee. Which of the following responses should the nurse make? 2) Assist a client to ambulate using a gait belt. d. Routine acquisition of a urine specimen The nurse caring for the client at the time of death requests organ donation c. I'll clean the inside of the container with a wipe A client with exacerbation of COPD reporting dyspnea. a. Shakes the soiled linen to remove any toilet paper remnants Initiative vs guilt Narrative interaction a. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. a. I'll provide more stimulation in his environment b. Which of the following actions is an example of a violation of confidentiality? Those clients who may be discharged or transferred will be informed, but it is not appropriate to alert every client.