Select all that apply. 2. 3. Which of the following actions should the nurse take? a. The charge nurse's best response is to first obtain the needed information to make the best decision. Which of the following responses should the nurse make? Correct: This group of clients is primarily med surgical. Select all that apply 3. A nurse is teaching a client about carbon monoxide poisoning. 9. c. Irrigating a client's abdominal wound Which of the following tasks should the nurse delegate to assistive personnel (AP)? d. I will take my medications at the first sign of an attack, d. To identify delayed gastric emptying (the nurse should measure the amount of unabsorbed formula from the previous feeding to identify delayed gastric emptying; if it is delayed the nurse should avoid overfeeding the client and causing gastric distention), 42. An adult (18 years or older) can create an advanced directive. 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. d. Proceed with the preparation of the patient's surgical procedure, 15. Encourage client to express grief related to loss of independence. 1. The expected standard of care was strict bed rest), 96. The spouse can rescind the Advance Directive if the client becomes unresponsive. Respite care allows the primary caregiver time away from day-to-day care responsibilities 3. c. Open the right flap with the left hand Witness the client's signature A client requesting assistance packing his belongings for discharge later today.. Select all that apply. Client diagnosed with Guillain-Barre' who is receiving ventilator support. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 2. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen (nurse should remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results), 56. a.) c. I'll need to shave the hair off the skin where I place the electrodes d. Voided 30 mL frequently 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. Ask the charge nurse to evaluate the intervention. b. Verbalize understanding of how the client feels A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. 3. The nurse should initiate a referral with which of the following members of the interprofessional health care team? b. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. Which of the following actions should the nurse take? 4. 4. This is not a situation that requires the LPN to notify the primary healthcare provider. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Provide a between meal supplement to the client. Incorrect: The RN is responsible for collecting data. c. Discard the tablet and obtain another dose of medication 4. "Please explain what you mean by the word 'nervous'.". Which of the following RNs should not be assigned to this baby? Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. Correct: The client must have lost decision-making capacity because of a condition that is not reversible or must be in a condition that is specified under state law, such as a terminal, persistent vegetative state, irreversible coma, or as specified in the Advanced Directive. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. Normally, red blood cells are flexible and round, moving easily through blood vessels. a. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. Perform range of motion (ROM) exercises at least 2-3 times daily e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. Which of the following actions should the nurse take? a. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day Remind the client to avoid tight fitting clothes. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 3. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. A nurse is planning to discharge a client who has quadriplegia to his home. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. The client post PEG placement is stable. a. Two hours . The client receives home health care and spends most of his day in a reclining chair. Which of the following actions should the nurse take? Perform the Heimlich maneuver The other options may be correct but are not the best first action. a. b. Assigning blame for the changes to administration will not help staff adjust. 1. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Sit side-by-side with the client Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. This client needs careful monitoring and specialized care. a. Which clients would be appropriate assignments for the LPN/LVN? The area surrounding the insertion site feels warm to the touch When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. d. Services are centered in long-term care facilities, a. The client asks about his medications and their effects. 2. 2. Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. This client is not the nurse's first priority. 5. 4. C. Review a low-sodium diet for a client who has hypertension. Use adult diapers to prevent frequent clothing changes The client's self-report of pain severity The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. The stem does not indicate any loss of neurological function resulting from the seizure activity. Which of the following should the nurse include as a criterion for applying restraints? Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. 5. a. Nothing life threatening. Encourage the client to use self-exploration The nurse prefers to check all vital signs on all clients. Which of the following info should the nurse include? Suggest splitting the shift with another nurse. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 2. Comatose client with end stage chronic obstructive pulmonary disease. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 4. Although this will require assessment, this client is not the priority at this time. The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. 3. A nurse asks a client to share personal stories. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? 1., 4., & 5. 5. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. 6. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. 3. Administer tap water enemas until clear at 6 AM. The RN with 10 years' experience pulled from the ER. A nurse has completed an informed consent form with a client. Twist at the waist when she moves an object to one side Explore the client's feelings A lack of rapid eye movement (REM) sleep Start MgSO4 at 3g/hr IV Which of the following approaches should the nurse use when using confrontation? Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. 3. Correct: The only procedure listed that is within the LPN/LVN's practice range is changing the colostomy bag. Provides safe, effective delivery of patient care in . 1. c. Paraphrasing 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Correct: Hot water may damage dentures so intervention is needed. Simply accept the assignment since overtime is mandatory. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. 1. Write N next to the nonessential clauses and E next to the essential clauses. Incorrect: The nurse is responsible for evaluating a client. A nurse is assessing a client at a follow-up clinic for acute low back pain. d. Reduced blood viscosity, a. Auscultating heart sounds Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. 1., 2., 4., & 5. Notify the board of nursing (BON) that the float nurse is an alcoholic. 1. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department The nurse suggest that the family might need to respite care services. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Which client can be assigned to the LPN? Providing a passive response d. Arguing, a. I'll apply ankle to my ankle today and tomorrow (the RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation), 16. A. The supervisor can only send one LPN/LVN to the floor. Receive report from the emergency department (ED) on a new client. b. I will come back later and we can talk d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). 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. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. 1. 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. c. Inflate the balloon when the urine flow stops The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. A charge nurse is observing a group of newly licensed nurses. Tenderness over the symphysis pubis This service began with the client's admission to the hospital, 18. 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. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? 1. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. This client could be transferred with traction still maintained. Correct: The client has the right to be involved in the decision making of their care. 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.) c. Measurement of residual urine after urination Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. Place in priority order. Include any relevant statements the client made about the ulcer, 64. d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound The client should be assessed first to rule out respiratory difficulty and hemorrhage. leadership management of care nurse on unit is providing care for group of clients. A nurse is caring for a client who expresses anxiety about his impending surgery. The client can indicate desire for Do Not Resuscitate (DNR). Serve food that have a hot/cold balance A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Of my three brothers and sisters, my sister Giselle has the best sense of humor. _____The house that we lived in for nine years has been sold. 1. Select all that apply a. This is an appropriate and safe action for the unlicensed nursing assistant to do. 3. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. 3. d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. which client would be most appropriate to assign a licensed practical nurse (lpn)? b. I will keep the fluorescent ceiling light on in my room at night Documentation of what occurred, and the client's assessment is required in the nurse's notes. 2. One nurse lifting as the client pushes with his feet
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