Place in priority order. To remove gastric acid that might cause dyspepsia Now, in Option #2, we see a dangerous prescription. a. 3. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? d. I will begin once the client's insurance company approves discharge coverage, b. Remember airway, breathing and circulation (ABCs). Dr. Frankenstein had seen himself as a(n) ?\underline{? Which client should the nurse see first? Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 4. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. What action should the nurse take after mistakenly administering the wrong medication? The nursing supervisor may be able to assist with client care until another nurse can come in to work. 3. c. I suggest you talk with a mental health counselor about your concerns Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. d. principal. 1. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Place the pack on a sterile work surface Administering IV pain medication to a two day post op client. 1. 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. A nurse is orienting a new assistive personal (AP) to the unit. 2. (Select all that apply) Autonomy vs shame and doubt The nurse has been assigned four clients. Irrigate a client's ear canal. The provider must renew a restraint prescription every 8 hr. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. A nurse is caring for a client in the orientation phase of the nurse-client relationship. Pain e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. Which of the following actions is the nurse's priority? 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. 5. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Limit the client's fluid intake in the evening b. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). d. Go to employee health services, b. Incorrect: The purpose of a cystogram is to examine the inside of the bladder to confirm the presence or absence of abnormalities, or even obtain a biopsy. So, the UAP can assist a client to brush and floss teeth. Once the client is stable, the UAP could perform this task. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. In the following sentences, circle each incorrectly used lowercase letter. Incorrect: An experienced neurological nurse should be assigned to this client due to the possibility that damage to the hypothalamus which controls body temperature has occurred. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 2. Which of the following instructions should the nurse include? 4. b. a. The other options may be correct but are not the best first action. A nurse is admitting a client from a long-term care facility. Report of feeling pressure Return any fresh linen not used for a client to the linen supply area Select all that apply Checking capillary refill beneath the client's fingernail An Advance Directive includes a Living Will and a Medical Power of Attorney. 1. Performing passive range of motion (ROM) on the client with right sided paralysis. a. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. Clients over the age of 65 must have a saline lock according to facility policy Which of the following actions by the nurse is considered an indirect nursing care activity? d. Identifying the client by name when making a referral for home health services, 30. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Which of the following findings should the nurse expect? d. I decline this opportunity at this time, b. Suggest splitting the shift with another nurse. 2. Which clients would be appropriate assignments for the LPN/LVN? c. I will inspect my crutches everyday for signs of wear Ask the primary healthcare provider to suggest the best oral care procedure. 1. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 3. The nurse caring for the client at the time of death requests organ donation 2. A nurse is caring for a client who has a wound infection. 3. & 5. d. Remove tea and coffee from meal trays, b. Licenced practical nurses are a little less educated than registered nurses. Documentation is a communication tool for the interprofessional health care team. a. I will begin 48 hr before the client's discharge In what order should the nurse assess assigned clients following shift report? (Select all that apply.) Explain administration is demanding a decreased overtime. a. a. 2. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. The last client would be the one needing dietary education. Client reporting a headache and has a fruity breath. Which tasks should the charge nurse complete at the end of the shift before leaving for the day? Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 1. Incorrect: Moistening the dentures will ease insertion. 4. 3. a. Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? b. Irrigate the NG tube with 100 mL of sterile water 2. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a 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 There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. A nurse is caring for a client who expresses anxiety about his impending surgery. A charge nurse is observing a group of newly licensed nurses. Which of the following activities should the nurse perform in this zone? Which of the following sites should the nurse plan to use to obtain the blood specimen? Prepare a list of clients who could quickly be discharged or transferred. 5. Both of these clients are terminal. During the admission of pediatric client with a compound fracture of the right femur following a sports injury, which delegation by the charge nurse is most appropriate? Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. Write the letter of your choice on the answer line. 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. Channel a. Charge nurses have integral roles in healthcare organizations. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. 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. The client then states, "I have changed my mind and do not want to have the procedure done." Handoff and Nursing Report Sheet. Which of the following instructions should the nurse include? A charge nurse role includes front line nurse supervisor, resource nurse, bed manager, peer reviewer, patient advocate, other charge nurse duties, and staff scheduler. Monitor for behavioral changes. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day What interventions can the nurse delegate to the LPN/VN? It also helps the client deal with issues that are important to him), 19. 4. Nothing life threatening. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 1. A nurse is caring for a client who is postoperative. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". The cause of the fall may be cardiac, but the question does not indicate this. When determining if the client is eating a well-balanced diet This task cannot be delegated to the LPN/LVN. 4. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. One important aspect is encouraging the flow of ideas between management and staff members. b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure Perform the Heimlich maneuver Have a pen and paper handy If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone.
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