What is the most appropriate action by the charge nurse? The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. b. Grape juice Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. 3. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. b. 3. The charge nurse might not have realized all the responsibilities of taking this team of clients. 2. a. 4. Nothing life threatening, but an assessment needs to be made regarding the ulcer. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? d. Providing information, a. b. Dons gloves to empty a urinary drainage device Write the letter of your choice on the answer line. This situation is considered an external disaster which means the hospital will be expecting multiple victims. c. Raised toilet seats Notify the primary healthcare provider. a. Incorrect: Informing is the same thing as teaching. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. The infusion rate has stopped but the tubing is not kinked Relax her abdominal muscles when she lifts an object Feed a client that had a stroke 3 months ago. Draining the colostomy bag on a client with diarrhea. The nurse is reviewing some clients' prescriptions. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. a. Charge nurses have integral roles in healthcare organizations. b. Did you think dehydration and fluid volume deficit? Which of the following findings should the nurse expect? The last client would be the one needing dietary education. A client receiving a blood transfusion that requires monitoring. Which clients would be appropriate assignments for the LPN/LVN? It contains a blank and is followed by four answer choices. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? Dentures should be stored in a denture cup. Which of the following statements should the nurse identify as an indication the client needs further teaching? 4. 4. In which situation should the nurse consult the client's advanced directive? 4. c. Inflate the balloon when the urine flow stops A nurse is administering a cold therapy application to a client. Based on these findings, to which of the following providers should the nurse request a referral for the client? Remind the client to tell the nurse when he has to urinate In the following sentences, circle each incorrectly used lowercase letter. 1. 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. 2. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. Alert all off-duty personnel to stand by in case of call- in. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. 5. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Thoracentesis reporting shortness of breath. 3. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. d. Determine if the client uses hearing aids, b. The nurse voices his concern to the charge nurse. 2. the nurse responds, "don't worry, no one will harm your family." Correct: Communication is important in delegation, as is follow-up. 5. 2. The client is reporting anxiety, discomfort, and a feeling of bloating. 4. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. The LPN should refuse the intervention. Once the client is stable, the UAP could perform this task. Speak to the UAP first and then decide if a between meal supplement is needed. Incorrect: The RN is responsible for assessment and evaluation. What is the major histological difference between thick and thin skin? A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. The nurse should assess the client for which of the following expected outcomes after catheter removal? Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. In what order should the emergency department triage nurse send these clients to a room for treatment? Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. 6. b. 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. This is an appropriate and safe action for the unlicensed nursing assistant to do. a. Bathtub with rails 1. c. Behaving defensively c. Paraphrasing The nurse cannot allow the UAP to perform advanced tasks. This would be an acceptable task to assign to the UAP. Which pediatric client care assignment is most appropriate for the charge nurse to delegate to the LPN/LVN? Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. The charge nurse must triage and assign clients to appropriate staff. c. Check to see if the suction equipment is working Evaluate pain relief after narcotic administration. Vital sign measurement The client is getting better. 3. 10. Have a pen and paper handy What should the nurse do first? Provide an adaptive feeding device for the client, 50. A client on a surgical unit frequently quarrels with the staff. 1. b. I will bear the weight of my body on my hands The nurse would then start the 24 hour urine once the 1st void has been discarded. Client to receive dietary education. a. Obtain a urine specimen from a client with an indwelling Foley catheter. Perform catheterization when you recognize the urge to void Correct: If suspicious behavior occurs, it is important to keep careful, objective records. a. I will keep spare crutch tips handy 4. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. d. Establishing the client's secondary medical diagnoses, b. Select all that apply One important aspect is encouraging the flow of ideas between management and staff members. b. I'll do exercises that strengthen my abdominal muscles c. Decreased sodium excretion Change the subject when the client behaves defiantly a. b. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Furosemide 40 mg PO q.d. Client scheduled for breast reconstruction after mastectomy. Risperidone .5 mg PO daily All these clients have a GI problem. 4. Try different methods of oral care on unresponsive clients to see what works best. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. The nurse could definitely be part of the committee. c. Holds the soiled linen against her body while carrying it to the linen bag PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. A client with a fractured right humerus who reports the cast is too tight. 3. a.) 4. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Which of the following actions should the nurse take first? It's just not the right time for me to do this Notify the board of nursing (BON) that the float nurse is an alcoholic. 2. Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Review a low-sodium diet for a client who has hypertension. Client reporting a headache and has a fruity breath. The nurse did not trust the new UAP. Select all that apply. It is quicker to administer medications intravenously in the hospital c. imaginary 4. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). A person can be designated to make medical decision in the event the client cannot. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Elevating the head of the bed 30- 40 for the client post thoracotomy Which task should the nurse take responsibility for completing? d. What have you done in the past to cope with this issue? 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. Triage and assign color-coded tags to each client. c. Can you tell me why you chose me? This protein is released by cells in the stomach. 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. Lisinopril 20.0 mg PO daily a. To confirm the placement of the NG tube This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. c. There is fluid leaking around the insertion site This is the most stable of the four clients which places this client last to be seen. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? Performing passive range of motion (ROM) on the client with right sided paralysis. Place in priority order. (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 The nursing supervisor may be able to assist with client care until another nurse can come in to work. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. a. I'll urinate a little then stop 1. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. A nurse is caring for a client who is scheduled for an elective surgical procedure. 1., 2., 3., & 4. 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. If a sentence is already correct, write CCC. 3. 4. The surgeon initially prescribes a clear liquid diet. 2. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. with this question, the nurse is using which of the following communication techniques? Something new could have occurred with the clients, making the assignments too heavy. This schedule may leave some clients too exhausted to visit with family. a. 1. b. Which of the following actions should the nurse take regarding informed consent? b. I should call my doctor if I find it harder to concentrate 4. 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 new UAP is efficiently completing all daily assignments accurately and in a timely manner. Ask for any staff objections to rearranging work hours. 4. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Focus on the client's present circumstances instead of his personal stories a. The client says, "go away, no one can help me." d. Explain oral hygiene to a client receiving chemo This is normal for clients with hemorrhoids. A nurse enters an older adult client's room to insert a saline lock. 3. A charge nurse is making client care assignments. Which of the following items should the nurse offer the client? When staff do not feel vested in any new process, there is a sense of underappreciation. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. Accept assignment, documenting personal concerns regarding work conditions. 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. Check environment for potential safety hazards. Incorrect: This prescription is written correctly. Ambulating a client who is 2 days post vaginal hysterectomy Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. A charge nurse is observing a group of newly licensed nurses. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. Select all that apply A medical-surgical LPN has been sent to a short-staffed pediatric unit. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. e. an open perineal wound, 92. A nurse asks a client how he is feeling. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. Nothing will get passed the complete blockage. 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. Although this will require assessment, this client is not the priority at this time. d. Discussing intake and output Correct: A long term care facility is considered a client's "home environment", and families are encouraged to visit often. Wears a gown when entering the room of a client who requires contact precautions During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 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 2. - Assisting a client to ambulate using a gait belt. d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. Announce the new changes at the monthly staff meeting. Dr. Frankenstein had seen himself as a(n) ?\underline{? 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. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. 1. (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 nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? a. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. a. which client would be an appropriate care assignment for this lpn? Schedule visiting times in two-hour increments so clients are not overwhelmed. Most of the following sentences contain errors in the use of modifiers and comparisons. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. 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. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Which client should the nurse see first? It is within the LPNs scope of practice to administer antibiotics. Which clients should be assigned to the CNA? Incorrect: The nurse is responsible for evaluating a client. d. Move to the opposite side of the pack and open the fourth flap, 54. Incorrect: It is out of the UAP's scope of practice to administer medication. The client attempted to climb over the side rails and fell The client states, "I'm feeling a bit nervous today." Select all that apply. b. Negligence Respite care allows the primary caregiver time away from day-to-day care responsibilities Document what the nurse believes was the cause of the ulcer development They are more direct when discussing issues Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. b. I will call the doctor and get the prescription Ask the primary healthcare provider to suggest the best oral care procedure. Ask the charge nurse to evaluate the intervention. Channel d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. Compartment syndrome could be developing which can impede circulation and cause nerve damage. c. Offer the client personal thoughts and beliefs Four clients arrive for their appointment at a diabetic clinic. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Collecting I & O totals for unit clients at the end of shift. What is the best response by the charge nurse? The nurse is responsible for the assessment of all vital signs of post-op clients. The client must understand the need for restraints A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. d. Reduced blood viscosity, a. Auscultating heart sounds The LPN can monitor the wound and provide care to the PEG insertion site. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. This is a task that can be delegated to the LPN/LVN. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. A nurse is preparing to move a client who is only partially able to assist up in a bed. So, now you must decide which of these high priority clients should be seen in what order. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. 4. Providing a passive response c. Discard any residual gastric contents A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. The area surrounding the insertion site feels warm to the touch The charge nurse should notify the nursing supervisor who will seek additional staff. 1. a. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Diltiazem is a calcium channel blocker that has been ordered as a titrated drip to slow heart rate and restore a regular rhythm. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 4. 5. Electric cords behind the furnitrure Rewrite each incorrect sentence to correct the error. b. Urinary frequency for several days This action is a defensive intervention, and does not address the quarrelsome behavior. a. 5. Client who is a diabetic experiencing diabetic neuropathy. The client with chronic emphysema has expected shortness of breath. What task would be best to assign to the LPN/LVN? Which of the following actions is an example of a violation of confidentiality? The client is apparently stable and does not require any advanced assessment skills or specialized care. Cystogram reporting burning on urination. Which of the following statements should the nurse identify as an indication that the client requires further clarification? This is an appropriate prescription. Providing hygiene care to a client who is HIV positive c. Rephrase statements the client does not hear What is the best care assignment for this client? Select all that apply. Allow families unlimited visitation around the clock to meet their schedules. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. b. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Incorrect: This again is assessment which is the role of the RN only. A. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. Serve food that have a hot/cold balance Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. 1. Encourage client to express grief related to loss of independence. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. 2. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. What was the hint? b. I will keep the fluorescent ceiling light on in my room at night 7. Have another nurse guard the medication preparations until the nurse returns A lack of rapid eye movement (REM) sleep Notify the primary healthcare provider of transfer completion. Reporting laboratory findings to a member of the client's family (the only people allowed to receive info are those that the client has given permission and those that are working with the client and their case), 29.
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