2. An adult (18 years or older) can create an advanced directive. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Schedule visiting times in two-hour increments so clients are not overwhelmed. Lumbar puncture reporting a headache. c. Document in the client's medical record that she completed an incident report Select all that apply An LPN/VN has been floated to the emergency room following a chemical plant explosion. 3. Which of the following methods should the nurse plan to use? b. I will begin once the client's discharge order is written 1. 1. Review a low-sodium diet for a client with hypertension. Change the subject when the client behaves defiantly Select all that apply 1. Which of the following actions should the nurse take? 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). Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. b. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 3. 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? a. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 4. 4. a. Alcoholic Anonymous A nurse is caring for a client who has a hip fracture that requires surgical repair. c. The nurse may serve as a witness to informed consent for organ donation 6. Which of the following statements should the nurse make? Which of the following actions indicates that the AP understands the principles of infection control? Which of the following actions should the nurse take? Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 4. There are a total of 10 adult clients. 1. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago - Assisting a client to ambulate using a gait belt. The best practice committee utilizes current research in their recommendations. d. Bend at the knees when picking up an object, 99. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? a. 6. The nurse is reviewing some clients' prescriptions. c. Consensus evolves in this stage December 5, 2020. 3. Which response by the LPN is appropriate in response to the inappropriate delegation? Call the family of a client suffering from dementia to discuss long term care placement. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. a. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. 4. A client with a fractured right humerus who reports the cast is too tight. Which of the following findings indicates that the client is meeting this goal? A nurse enters an older adult client's room to insert a saline lock. A nurse is prioritizing care for two clients at the start of the shift. 5. 4. a. 3. a. Auscultate breath should at least ever 2 hr Which of the following items should the nurse offer the client? This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. 208 a. c. Hold an object away from her body as she lifts it A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. Wrapping the dentures in tissue while the client sleeps Which of the following statements should the nurse identify as an indication that the client understands the discharge information? 2. A practical guide to making patient assignments in acute care The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. This client is not the nurse's first priority. Client to receive dietary education. 4. b. The client then states, "I have changed my mind and do not want to have the procedure done." 4. a. Correct: The UAP can remind the client to do something that has already been taught by the nurse. 1. A nurse is filling out an incident report after finding a client lying on the floor. 2. This is not a situation that requires the LPN to notify the primary healthcare provider. A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. 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. c. Helping the client into the shower A nurse is caring for a client who has a wound infection. Client who is a diabetic experiencing diabetic neuropathy. Obtain a bedside commode for the client's use A. Transporting a client who experienced a stroke 72 hr ago to the radiology department b. b. Urinary frequency for several days NUR 112 Practice Assessment Flashcards | Quizlet c. I suggest you talk with a mental health counselor about your concerns d. Test the pH of gastric aspirate, d. Determine if the client uses hearing aids, 86. Incorrect: This is not completely practical for everyone. 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. 1., 3, & 4. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. The surgeon initially prescribes a clear liquid diet. A cardiac step down unit has requested float staff because of multiple impending admissions. The client asks the nurse, "Why do I need that? A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. The client's self-report of pain severity A nurse is preparing medication for a client when another client has an emergency. 1. A charge nurse is making client care assignments. Initiative vs guilt & 3. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 3. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. It's just not the right time for me to do this The nurse should not be assigned to provide care if impairment is suspected. What task would be best to assign to the LPN/LVN? 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. Use the tablet's packaging to pick it up from the counter A nurse is caring for a client who has emphysema and has difficulty with mobility. 8. Focus on the client's present circumstances instead of his personal stories Prior to turning feeding back on, tube placement needs to be verified. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). Receive report from the emergency department (ED) on a new client. The unit is short one staff member and will receive a nurse from the medical surgical unit. d. What have you done in the past to cope with this issue? Teaching insulin self administration cannot be delegated to the LPN. The nurse does not know the skills of the new UAP. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Turn on local news for up-to-date information on the train derailment. Which of the following statements should the nurse identify as an indication that the client requires further clarification? 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. 2. 6. We do not know the extent of her injuries based on what the option tells us. Disconnect client's nasogastric (NG) tube suction to allow ambulation. Injuries from a motor-vehicle accident can be life threatening. If the client is unstable, the nurse would retain the role of measuring the vital signs. Which of the following actions should the nurse take first? Remove all metal necklaces This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The charge nurse should notify the nursing supervisor who will seek additional staff. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." When a family member asks how respite care can help, which of the following responses should the nurse provide? 3. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. This is an elderly client who is a new admit. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Obtain a urine specimen from a client with an indwelling Foley catheter. Two hours after other trays were picked up from the rooms, the nurse notes that the client's untouched tray is still at the bedside. The client receives home health care and spends most of his day in a reclining chair. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Which of the following actions should the nurse perform when opening the sterile pack? Did the words diabetic neuropathy make you think that a LPN should not be assigned to this diabetic? Aplastic Anemia Support Group. 1. Relax her abdominal muscles when she lifts an object b. A nurse is assessing a client who has narcolepsy. b. 4. 3. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. 4. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Checking capillary refill beneath the client's fingernail a. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. Client reporting epigastric pain and nausea after eating. c. Provide the client with a diet high in protein 2. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Client eating a simple-carb snack due to weakness. Accept the client's behavior as confrontational. A nurse is developing a plan of care for a client who practices Islam. a. This could indicate a worsening of this client's condition. e. Feed a client who had a stroke 3 months ago, 31. In what order should the nurse see the clients? 3. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). b. The nurse has just completed a 12 hour shift. 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. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". 4. In what order should the emergency department triage nurse send these clients to a room for treatment? he charge nurse is making client care assignments for the evening shift a. Irrigate a client's ear canal. "Please explain what you mean by the word 'nervous'.". Richied5864 Richied5864 . A nurse has completed an informed consent form with a client. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Question: A charge nurse is making client care assignments. Assign a nursing assistant to help the client with self-care activities. A nurse is teaching a client who has a history of falls about home safety. 4. b. 4. d. I have a set of my brothers' crutches in the basement I can also use, a. assignmentcafe.com - A charge nurse is making assignments for nursing The third client that should be sent back for treatment is the female client stating she has been raped. Which of the following physiological responses to prolonged immobility should the nurse expect? Incorrect: This group of clients needs specific teaching. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Select all that apply. Relief of urinary retention Reach around the pack and open the top flap away from the body Assist a client to ambulate using a gait belt. a. 1. 3. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. with this question, the nurse is using which of the following communication techniques? Which task is appropriate for the nurse to delegate to the experienced nursing assistant? The nurse caring for the client at the time of death requests organ donation b. and 16 g of fat. c. Notifying the provider of physical exam findings The client is getting better. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? Client two days post percutaneous endoscopic gastrostomy (PEG) placement. A client has been admitted with folic acid deficiency anemia. Drag and Drop the items from one box to the other. c. The client's culture Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. If your reasons for refusal were client safety, nurse safety, or an imperative personal commitment, document this carefully including the process you used to inform the facility (nurse manager) of your concerns. d. Assault, b. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? c. Distended bladder Remind the client to tell the nurse when he has to urinate Ask the primary healthcare provider to suggest the best oral care procedure. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. The first vital sign check was performed by the nurse.