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. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. b. c. Check to see if the suction equipment is working Protective (clients whose immune system is compromised, such as from chemo, AIDS, or after a stem-cell transplant, require a protective environment), 97. The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 1. This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. 1., 4., & 5. This protein is released by cells in the stomach. c. Distended bladder b. Wash the tablet off with alcohol and place it in a clean medicine cup Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. 1. It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). Which of the following statements should the preceptor make? A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Encourage client to express grief related to loss of independence. A nurse is preparing a sterile field. Which of the following explanations should the nurse provide? Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Something new could have occurred with the clients, making the assignments too heavy. 3. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. This stage is when testing occurs to identify boundaries of interpersonal behaviors Incorrect: The concern here is the client being fed their meal. A nurse who is breastfeeding her 4 month old. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? The nurse could definitely be part of the committee. Checking capillary refill beneath the client's fingernail 1. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Twist at the waist when she moves an object to one side Which of the following actions should the nurse take? 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. a. 1. c. They tend to use more verbal communication Correct: Traction should never be relieved without a primary healthcare provider's prescription. 4. 1. b. d. Proceed with the preparation of the patient's surgical procedure, 15. Anyone over age 18 can have an Advanced directive. Use the tablet's packaging to pick it up from the counter 4. This client will also need a lot of education regarding anti-rejection medications. Incorrect: The nurse is responsible for evaluating a client. a. Which task would be appropriate for the nurse to assign to an LPN/VN? A. Transporting a client who experienced a stroke 72 hr ago to the radiology department c. Take the client to the bathroom every 2 hr The client asks the nurse, "Why do I need that? c. Irrigating a client's abdominal wound The best practice committee utilizes current research in their recommendations. d. Go to employee health services, b. Explore the client's feelings Select all that apply The client post PEG placement is stable. 1. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). 4. So, the UAP can assist a client to brush and floss teeth. 2. A nurse is planning care for a female client who has an indwelling urinary catheter. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Also, making a surgical bed for the client returning from surgery is a basic procedure. d. Respite care is a continuation of psychological support after a family member dies. Which client should the nurse assess first? Ask the client to perform a return demonstration of insulin injection c. Measurement of residual urine after urination Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. Photo comes from the Greek word for light. d. Transporting a cerebrospinal fluid specimen to the lab A medical-surgical LPN has been sent to a short-staffed pediatric unit. All these clients have a GI problem. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. The provider must renew a restraint prescription every 8 hr. Pernicious Anemia Society d. Place the tablet directly into a medication cup, 36. The nurse should use close-ended questions when assessing which of the following factors? A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. What interventions can the nurse delegate to the LPN/VN? Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. a. An increased temperature will have a direct effect on the brain's metabolism and function. a. Encourage the client to use self-exploration Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. a. 2. 1. The nurse should call for immediate help so that a safe care environment is maintained for all clients. A nurse has completed an informed consent form with a client. So, now you must decide which of these high priority clients should be seen in what order. Client scheduled for breast reconstruction after mastectomy. However, providing care for missing teeth would also be within the LPN scope of practice. Prepare a list of clients who could quickly be discharged or transferred. b. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). Schedule visiting times in two-hour increments so clients are not overwhelmed. 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. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. The second client the nurse needs to see is the client diagnosed with gastroenteritis who had two 300 mL diarrhea stools in one hour. Remind the client to tell the nurse when he has to urinate The reason for the UAP not feeding the client needs to be determined. 4. The charge nurse might not have realized all the responsibilities of taking this team of clients. c. Review a low-sodium diet for the client who has hypertension 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. 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. Invite staff to contribute ideas on scheduling changes. 3. 6. 1. b. Massage any bony prominences to promote circulation Administer tap water enemas until clear at 6 AM. b. Negligence A nurse is caring for a client who has a hip fracture that requires surgical repair. This service focuses on teaching the primary caregiver to meet the client's needs A client requesting assistance packing his belongings for discharge later today.. Client reporting a headache and has a fruity breath. Which of the following interventions should the nurse include? If the client is unstable, the nurse would retain the role of measuring the vital signs. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 2. (Select all that apply.) Education A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. Incorrect: The client does need to have food; however, there is another action that should be performed first. d. I will place a bath seat in my shower to use when I bathe, b. b. I will come back later and we can talk 1. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. Confrontation should occur in the presence of a charge nurse or supervisor. a. I'll urinate a little then stop Which of the following actions should the nurse take? Elderly clients have special fluid and electrolyte issues after a fall. The client's self-report of pain severity The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). Correct. Yes! 3. What action should the nurse take after mistakenly administering the wrong medication? This client is at a high risk of infection. 1. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. c. Use an aggressive tone of voice d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. Wears a gown when entering the room of a client who requires contact precautions The client reports constipation for 4 days which may be an indication of worse problems. Which client should be assigned to the most experienced nurse? d. Complete an incident report, 70. c. 214 d. Droplet, d. Bend at the knees when picking up an object, 98. 2. Receive report from the emergency department (ED) on a new client. Delegate 2 nurses to work with the client. They are likely to wait for others to initiate conversation Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. (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 76. a. d. Establishing the client's secondary medical diagnoses, b. 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. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. 2. The nurse is using which level of communication at this time? Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. b. I can detect the presence of carbon monoxide by a metallic odor A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. A nurse is caring for a client who is about to have a colonoscopy. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. The nurse is planning care for a client admitted with Alzheimer's Disease. It would not be appropriate to overload this new employee with extra work. 2. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? B. Client who is a diabetic experiencing diabetic neuropathy. d. 216, 22. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Write N next to the nonessential clauses and E next to the essential clauses. Comatose client with end stage chronic obstructive pulmonary disease. Which of the following of Erikson's developmental stages should the nurse consider in the planning? 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 1. A nurse is preparing to move a client who is only partially able to assist up in a bed. When assigning nurses to patients, the charge nurse must consider the acuity of the patient's condition, the skills of the nurse, and the availability of other staff members. (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 55. 3. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Initiative vs guilt 4. A nurse is caring for a client who has limited hand movement. 2. This is an appropriate and safe action for the unlicensed nursing assistant to do. c. Notify the nurse manager d. Move to the opposite side of the pack and open the fourth flap, 54. 3. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. A client with fibromyalgia reporting generalized pain of 7 out of 10. Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. This determination is needed to assure client safety is being considered. There may be a good reason that the tray was not served. The client is apparently stable and does not require any advanced assessment skills or specialized care. 3. What should the nurse do first? The nurse also needs to be aware of the color and amount of urine voided. 5. Assist a client to ambulate using a gait belt. An Advance Directive includes a Living Will and a Medical Power of Attorney. Respite care allows the primary caregiver time away from day-to-day care responsibilities 1. The charge nurse knows what client would be most appropriate for this LPN? 3. 4. The LPN can monitor the wound and provide care to the PEG insertion site. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. 4. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 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. 3. (Select all that apply.). 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. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. 1. 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. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Ask client if they are eating small, frequent meals. a. b. I will try to anticipate and avoid stressful situations when possible a. A post-cardiac catheterization needing assistance with bedpan. 4. c. I will complete the smoking cessation program I started The nurse is using which of the following therapeutic communication techniques? Each ROM movement should be repeated 5 times during the session. e. Feed a client who had a stroke 3 months ago, 32. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Thoracentesis reporting shortness of breath. 2. 3. Although this will require assessment, this client is not the priority at this time. The expected standard of care was strict bed rest), 96. This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. c. Foot The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. 4. A nurse is caring for a client who is scheduled for an elective surgical procedure. This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. b. Report of feeling pressure Provide positive feedback to the UAP. Which of the following info should the nurse include? The nurse voices his concern to the charge nurse. Correct: The client has the right to be involved in the decision making of their care. leadership management of care nurse on unit is providing care for group of clients. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. Determine caregiver's stress level and coping strategies. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Everyone knows there are others who can chair this committee better than me Each state BON differs in that also some have treatment programs they administer themselves.
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