In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. Client eating a simple-carb snack due to weakness. Briefly assess every client. Ask the charge nurse to evaluate the intervention. 2. (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 Which of the following types of torts has the nurse committed? The reason for the UAP not feeding the client needs to be determined. b. Places the soiled linen in the floor before bagging it 1. Perform range of motion (ROM) exercises at least 2-3 times daily This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. A. Making client care assignments As the RN charge | Chegg.com Delegate 2 nurses to work with the client. Airborne NUR 204 ATI Management of Care Ch. 1-9 Flashcards | Quizlet However, it remains true pain for this client and the client would need intervention to help manage this pain. 2. Encourage the client to use self-exploration Monitor client for pain while assisting with ambulation. The nurse should identify that this client is demonstrating which of the following kulber-ross stages of grieving? The nurse suggest that the family might need to respite care services. Aplastic anemia is a rare but serious condition. The client is getting better. 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. One important aspect is encouraging the flow of ideas between management and staff members. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. a. 2. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. Select all that apply. 1. Which actions should be instituted by each unit's charge nurse? Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. All these clients have a GI problem. Gown 3. 2. b. The nurse also needs to be aware of the color and amount of urine voided. 3. Temporary urinary retention (common for clients to develop after removal), 90. The charge nurse must triage and assign clients to appropriate staff. 3. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. The nurse asks why the client needs to know this. Review a low-sodium diet for a client who has hypertension. A list of current medications is sent to the facility. Handoff and Nursing Report Sheet. 4. Relief of urinary retention d. The nurse has already considered alternatives to restraints, a. 3. (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 Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Which of the following actions should the nurse include in the plan? The charge nurse tells a nurse that multiple sick calls from the upcoming shift has occurred. b. When asking the client about his receptiveness to the transfer c. I'll clean the inside of the container with a wipe Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? 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. Provides day to day direction and supervision to assigneddirect patient care staff . d. What have you done in the past to cope with this issue? Select all that apply. 4. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. 4. Make nursing assignments appropriate to the skill level . Warm the feeding solution to the body temperature 3. d. Custard c. Confrontation They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. 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. This client can wait until the others are treated. M2.4 Making Client Care Assignments - GECC.pdf - Course Hero Select all that apply 1., 2., 4., & 5. 2. Dr. Frankenstein had seen himself as a(n) ?\underline{? c. imaginary (Select all that apply.). Administering IV pain medication to a two day post op client. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? b. Which of the following actions is the nurse's priority? a. Place in priority order. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. A nurse is preparing medication for a client when another client has an emergency. 3. During exacerbation, the client will have many diarrhea stools. It happened so long ago - just get over it!" c. Distended bladder The nurse is focusing on which of the following elements of the communication process? Which of the following findings should the nurse identify as a safety risk? This includes medication enemas. c. I suggest you talk with a mental health counselor about your concerns 3. Prepare a list of clients who could quickly be discharged or transferred. Nursing Brain Sheet 4 Patients - luoe.expertoendermatologia.es 1. Incorrect: The concern here is the client being fed their meal. Which of the following actions should the nurse take? Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Correct: Traction should never be relieved without a primary healthcare provider's prescription. Notify the nursing supervisor of the situation. Notify the board of nursing (BON) that the float nurse is an alcoholic. 2. Notify the surgeon that the client wishes to withdraw informed consent for the procedure It is quicker to administer medications intravenously in the hospital 2. c. Palpating for pedal edema Based on this information,what should the nurse do? 3. What is the most appropriate action by the charge nurse? b. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. Incorrect: This client is exhibiting early signs of increased intracranial pressure. a. Bathtub with rails Both of these clients are terminal. Show client who has conjunctivitis how to clean the eyes. 3. Call the family of a client suffering from dementia to discuss long term care placement. Accept assignment, documenting personal concerns regarding work conditions. The nurse voices his concern to the charge nurse. Which of the following actions indicates that the AP understands the principles of infection control? An experienced nurse would be assigned to this unstable client due to the possibility of a reoccurring hemorrhagic stroke resulting from the client's hypertension. b. Grape juice Education 3. Which of the following actions should the nurse take? 4. 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? Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. c. Take the client to the bathroom every 2 hr b. a. 3. 4. e. Dysuria, 49. c. Providing anticipatory guidance to a client in crisis The best practice committee utilizes current research in their recommendations. A two-hour limit on visits discourages quality time. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. 1. c. There is fluid leaking around the insertion site Sudden attacks of sleep 4. 3. 4. is a new graduate in orientation. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. 3. Explain to the RN that all the nurses have the same number of clients. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? 4. c. Raised toilet seats Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? d. I'll put a heating pad on my ankle at bedtime tonight, d. I have a set of my brothers' crutches in the basement I can also use (the client should not use crutches that belong to someone else; the crutches must fit body dimensions), 17. A client receiving a blood transfusion that requires monitoring. c. Inform the surgical team to cancel the client's surgery 3. 3. a. A nurse is providing discharge teaching for a client who requires home oxygen therapy. 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. 4. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Ask the primary healthcare provider to suggest the best oral care procedure. 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. 3. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. 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. Incorrect: The RN is responsible for assessment and evaluation. 2. Most of the following sentences contain errors in the use of modifiers and comparisons. 2. This is outside the scope of practice for the LPN/LVN. c. Changing a dressing, 78. d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. The nurse who made the medication error should take which of the following actions first? December 5, 2020. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Which response by the LPN is appropriate in response to the inappropriate delegation? d. Respite care is a continuation of psychological support after a family member dies. 5. a. Select all that apply. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. This documentation should go to your manager. 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. 2. 2. What options would be appropriate for the nurse to take? 1., 2., 3., & 4. 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. The Charge Nurse will lead or direct licensed and non-professional staff in the delivery of direct Resident care and support functions. A client diagnosed with rheumatoid arthritis needing discharge teaching. Which of the following findings associated with urinary retention should the nurse expect? A nurse is assessing a client who is experiencing prostatic hypertrophy. Confrontation should occur in the presence of a charge nurse or supervisor. d. Highly concentrated urine, 91. 2. Correct: Talking to the nurses about client concerns and completing the client assignment sheet for oncoming staff will provide for a thorough shift change report. 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. 4. Feed the client after warming the food. b. c. Document in the client's medical record that she completed an incident report Obtain a bedside commode for the client's use A nurse is orienting a new assistive personal (AP) to the unit. 1., 2., & 5. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. b. Summarization They are likely to wait for others to initiate conversation Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. A nurse just back from maternity leave. To which of the following rooms should the nurse assign the client? Which of the following statements should the nurse identify as an indication that the client needs further teaching? A charge nurse is making client care assignments. A nurse is preparing to move a client who is only partially able to assist up in a bed. Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. c. Measurement of residual urine after urination The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. Place the client in a lateral position A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. 2. 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. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Documentation of what occurred, and the client's assessment is required in the nurse's notes. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. a. one of the licensed practical nurses Get the answers you need, now! c. Respite care helps relieve pain and promote comfort b. Assigning tasks to an AP Correct: If suspicious behavior occurs, it is important to keep careful, objective records. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. A charge nurse is making client care assignments. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. The client states, "I am so nervous about what the doctor might find during the test." 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. Incorrect: Medications are not transferred with the client to a new facility. 2. 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). 212 Incorrect: Moistening the dentures will ease insertion. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. The client states, "I'm feeling a bit nervous today." Correct: Did you notice the hint? Semi-formed stools are great news! So, the UAP can assist a client to brush and floss teeth. 5. b. Which of the following instructions should the nurse include? A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. _________________ (magnanimous), a. generous Which of the following actions should the nurse take? Yes! 3. a. This is an appropriate and safe action for the unlicensed nursing assistant to do. Two hours . Discuss the assignment with another LPN. c. Use intermittent eye contact 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. 1. a. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. The RN with 2 weeks' experience on the postpartum unit. A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." A charge nurse is making assignments for an oncoming shift. a. This referral would be appropriate. Include any relevant statements the client made about the ulcer, 64. There is a trailing zero after the prescribed dose. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. Incorrect: This would unnecessarily alarm the clients. A nurse is caring for a client who has limited hand movement. 2. A nurse is developing a plan of care for a client who does not speak the same language as the nurse. Ask the RN why the assignment is too heavy. UAPs can assist with elimination and are taught how to measure output. Following a large hurricane, multiple clients arrive at the emergency room for treatment. b. I'll rewrap my ankle starting from the knee down The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Which of the following actions should the nurse take? d. Go to employee health services, b. b. d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. The best practice committee works to improve clinical practice based on current research. 4. a. A nurse is caring for a client who expresses anxiety about his impending surgery. The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Solved A charge nurse is making client care assignments. | Chegg.com c. Check to see if the suction equipment is working a. I wish I didn't have to attach the electrodes to my skin a. Answer the following question to test your understanding of the preceding section: In which situation should the nurse consult the client's advanced directive? d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) 3. 4. Correct: The client who has a cast and requires pain medication is a stable and predictable client. 5. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day This client should report an improved respiratory, not shortness of breath. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. Use adult diapers to prevent frequent clothing changes The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). 5. Vaginal delivery of fetal demise, C-section with pneumonia, 32 week gestation with lymphoma. 3. Did you recognize ureterolithiasis as "kidney stones"? Correct: The unlicensed nursing assistant should not turn tube feedings off or on. Allow families unlimited visitation around the clock to meet their schedules.

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