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. 4. A nurse is caring for a client who states, "I have got to get out of this hospital! 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. The third client that should be sent back for treatment is the female client stating she has been raped. 1. Which response by the LPN is appropriate in response to the inappropriate delegation? Incorrect: The client does need to have food; however, there is another action that should be performed first. There are a total of 10 adult clients. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. Talk to each nurse about concerns related to assigned clients. 2. Have another nurse guard the medication preparations until the nurse returns The charge nurse of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. b. c. Discard the tablet and obtain another dose of medication There is a trailing zero after the prescribed dose. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. and 16 g of fat. Because positioning on a bedpan requires rolling of the client, an RN should be assigned to assess the insertion site and monitor for the presence of bleeding. Offer to take one of the clients. During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. 2. 4. The nurse is focusing on which of the following elements of the communication process? Perform the Heimlich maneuver Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? When the licensed person cannot determine this, the task should not be delegated. Assigning blame for the changes to administration will not help staff adjust. 2. Did you recognize ureterolithiasis as "kidney stones"? d. Providing information, a. d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. 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. 3. 2. Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. Which referral would most likely be appropriate for the nurse to make? Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. A charge nurse is observing a group of newly licensed nurses. 2. d. Custard Remove all metal necklaces Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Complete blockage of the large intestine. The client's self-report of pain severity, 88. Which preoperative prescription should the nurse question? This would be an acceptable task to assign to the UAP. A client with an above the knee amputation reporting phantom pain. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. 76. Assist the float nurse with the clients case. 3. Which actions should be instituted by each unit's charge nurse? The charge nurse knows what client would be most appropriate for this LPN? 4. 4. 4. 5. 1. Which group of clients should she assign to the medical surgical nurse? 5. This invasive procedure results in some edema to the vessel used for the procedure but assessing only one pedal pulse does not provide sufficient data to verify a complication. Check environment for potential safety hazards. The body needs vitamin B12 to make red blood cells. The nurse caring for the client at the time of death requests organ donation Announce the new changes at the monthly staff meeting. Client #1 has COPD, and, although complaining of shortness of breath, that is not unusual for clients with this diagnosis. b. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. a. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. a. c. Washes and rinses her hands for 10 seconds Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. e. an open perineal wound, 92. Drag and Drop the items from one box to the other. c. Visual observation for nonverbal signs of pain Write N next to the nonessential clauses and E next to the essential clauses. 4. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. The nursing supervisor may be able to assist with client care until another nurse can come in to work. c. Why are you crying? The nurse is planning care for a client admitted with Alzheimer's Disease. d. Perception 4. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. 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. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage 4. C-section planning discharge, postpartum infection, mastectomy. which client would be an appropriate care assignment for this lpn? Obtain a client's consent 3. Allow families unlimited visitation around the clock to meet their schedules. 2. 4. Which of the following actions indicates that the AP understands the principles of infection control? Select all that apply. b. Irrigate the wound with an antiseptic prior to obtaining the specimen The nurse is caring for four clients. which of the following actions should the nurse perform? b. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. d. Move to the opposite side of the pack and open the fourth flap, 54. c. Review a low-sodium diet for the client who has hypertension Serve milk products separately from meals Client with ureterolithiasis who requires frequent PRN pain medication. with this question, the nurse is using which of the following communication techniques? Correct: The client may be experiencing a myocardial infarction and requires further assessment. Occupational therapist When asking the client about his receptiveness to the transfer c. Use an aggressive tone of voice The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. A nurse is preparing a sterile field. A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following tasks should the nurse delegate to AP? This situation requires an immediate neurovascular check to determine if intervention is needed to relieve the pressure and restore circulation. Collecting I & O totals for unit clients at the end of shift. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. d. Motor impairment, 84. a. 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 first vital sign check was performed by the nurse. 5. 1. 2. Place the client in a lateral position Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Based on the information provided in report, which client condition should be the nurse's priority? Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. 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. b. eminent We see that the temperature is already elevated, which makes us worry that infection is present. 1., 3, & 4. d. Left forearm, b. b. The reason for the UAP not feeding the client needs to be determined. This task cannot be delegated to the LPN/LVN. c. Palpating for pedal edema c. I'll bear weight on my ankle for 10 minutes every hour b. (Select all that apply.) So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. An adult (18 years or older) can create an advanced directive. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. 3. A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. A school-aged child with a fractured femur who is in balanced suspension traction. Which clients should be assigned to the CNA? e. Dysuria, 49. 3. Simply accept the assignment since overtime is mandatory. Relax her abdominal muscles when she lifts an object So, the UAP can assist a client to brush and floss teeth. This client needs careful monitoring and specialized care. c. Discard any residual gastric contents 2. b. Rewrite each incorrect sentence to correct the error. A nurse just back from maternity leave. 1. 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. b. Which of the following tasks should the nurse delegate to assistive personnel (AP)? c. Decreased sodium excretion e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. 3. c. Raised toilet seats This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. The nurse is using which level of communication at this time? 3. This would be out of the UAP's scope of practice. However, there are some basic points which are standard among all facilities. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). The area surrounding the insertion site feels warm to the touch, 61. A nurse is performing care activities for a client in the zone of touch that requires his consent. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. Client eating a simple-carb snack due to weakness. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. a. Incorrect: The nurse retains the responsibility for the delegated task. This client is stable and predictable. Incorrect: This group of clients needs specialized care. Notify the nursing supervisor of the situation. This stage involves constructive efforts on the part of the group members Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. d. What have you done in the past to cope with this issue? Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. Documentation of what occurred, and the client's assessment is required in the nurse's notes. 2. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department 4. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? c. I will begin upon the client's admission to the facility The client asks the nurse, "Why do I need that? b. & 5. 2. The supervisor can only send one LPN/LVN to the floor. 2. 5. Incorrect: This prescription is written correctly. b. A nurse who is breastfeeding her 4 month old. A nurse receives a client care assignment from the charge nurse that he believes is unfair. a. Aplastic Anemia Support Group. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter This could be devastating to the client if the decimal point is missed and the client receives 200 mg instead of the intended 20 mg of lisinopril. The charge nurse is responsible for ensuring that the patients on the unit are properly cared for in a safe and efficient manner. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Soaking the dentures in hot water Accept the client's behavior as confrontational. 3. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. The client with cystitis is stable and has a predictable outcome. 1. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. 4. a. c. We administer all medications intravenously to clients in this unit Incorrect: The RN is responsible for assessment and evaluation. b. B. Making Client Care Assignment NUR 211: Module 4 Assignment Rationale: The patient is stable, she will need to teaching on self-care after a pacer insertion. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. In what order should the emergency department triage nurse send these clients to a room for treatment? Correct: The client who has a cast and requires pain medication is a stable and predictable client. Ask the charge nurse to evaluate the intervention. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. 6. b. Use the tablet's packaging to pick it up from the counter 2. c. Behaving defensively Performing passive range of motion (ROM) on the client with right sided paralysis. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. 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. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. Select all that apply Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? Select all that apply A nurse is developing a plan of care for a client who practices Islam. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. a. a. Reposition the client every 3 hr Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. The client is considered unstable until assessed by the nurse. Channel The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. d. principal. 2. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. e. The urge to move the legs when trying to sleep, 66. Which client should be assigned to the most experienced nurse? There is a possibility that a hypothermia blanket may be prescribed. 3. Each state BON differs in that also some have treatment programs they administer themselves. Which of the following should the nurse include as a criterion for applying restraints? 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 client with a fractured right humerus who reports the cast is too tight. The cause of the fall may be cardiac, but the question does not indicate this. A nurse who is 10 weeks pregnant. What task would be best to assign to the LPN/LVN? Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Licenced practical nurses are a little less educated than registered nurses. Client diagnosed with inoperative brain tumor who is confused. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Elderly client who fell and fractured the left femoral neck. Limit the client's fluid intake in the evening Denial 1. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? The provider must renew a restraint prescription every 8 hr. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. A nurse is teaching a client about carbon monoxide poisoning. This situation is considered an external disaster which means the hospital will be expecting multiple victims. Airborne 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. Speak to the UAP to determine what happened with the feeding. What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? Administering IV pain medication to a two day post op client. d. They disclose more personal information, a. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. 4. 2. Removing the client's dentures PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. b. These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. Everything will be okay A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. d. Do you think crying will help? 1. A nurse is assessing a client at a follow-up clinic for acute low back pain. a. Warm the feeding solution to the body temperature Correct. Semi-formed stools are great news! Remember, pick the killer answer first! 2. (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. b. Battery leadership management of care nurse on unit is providing care for group of clients. Well, do you see the q.d.? d. Voided 30 mL frequently Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. Feed the client after warming the food. 1. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. 4. The client will need to be assessed, but there is no specific indication the respiratory status is presently compromised. 3. 1. a. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Increased insulin production 4. Besides yourself, there are the following staff: Your unit has 12 beds. Question: A charge nurse is making client care assignments. A nurse is assessing a client who has narcolepsy. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. 3. c. Hand-off technique 3. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Showing disapproval Incorrect: Informing is the same thing as teaching. So, now you must decide which of these high priority clients should be seen in what order. A nurse is providing discharge teaching for a client who requires home oxygen therapy. Electric cords behind the furnitrure 3. Client to receive dietary education. What information should the nurse include? A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. The nurse who made the medication error should take which of the following actions first? Which of the following findings should the nurse expect? 5. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. This client will also need a lot of education regarding anti-rejection medications. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. 3. is a new graduate in orientation. To remove gastric acid that might cause dyspepsia INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. Which clients could be assigned to an LPN? 1. Select all that apply. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Which of the following responses should the nurse make? Currently, your census is 11, with one empty bed. There are a total of 10 adult clients. 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. Did you think dehydration and fluid volume deficit? c. Helping the client into the shower 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. 2. Notify the surgeon that the client wishes to withdraw informed consent for the procedure (the client has the right to withdraw consent therefore the surgeon should be the one notified of the request), 14. Suggest splitting the shift with another nurse. The healthcare team should recognize the client as the center of the team. 4. Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. Which of the following actions should the nurse perform when opening the sterile pack? Two nurses lifting the client under the shoulders 2. Draining the colostomy bag on a client with diarrhea. "Please explain what you mean by the word 'nervous'.".

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