1. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? Dentures should be stored in a denture cup. (Select all that apply.). Comatose client with end stage chronic obstructive pulmonary disease. Provide a between meal supplement to the client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? 4. Take several shallow breaths during the procedure Based on the information provided in report, which client condition should be the nurse's priority? d. Voided 30 mL frequently, 48. 1. 4. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. a. I will keep my walker at the end of my bed a. The client would develop severe cramping. Provides day to day direction and supervision to assigned direct patient care staff. A nurse is planning to discharge a client who has quadriplegia to his home. e. Time, c. The nurse may serve as a witness to informed consent for organ donation (nurses may witness the consent for organ donation after a specially trained professional requests consent), 23. It involves people who are constantly changing-their conditions improve and deteriorate, they're admitted and discharged, and their nursing needs can change in an instant. c. Gender a. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. This is a task that can be delegated to the LPN/LVN. Refuse the delegated intervention. The nurse is caring for four clients. a. Broth This is outside the scope of practice for the LPN/LVN. a. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). 4. Incorrect: The nurse may trust the UAP; however, the nurse has not been able to determine the competency of the new staff member. A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. The nurse prefers to check all vital signs on all clients. A nurse is caring for a client who has a wound infection. 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. 6. It can result in muscle spasm and tissue damage. 3. Tenderness over the symphysis pubis b. I'll do exercises that strengthen my abdominal muscles This is likely cholelithiasis, which will need to be checked out. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. The report should contain consequences. Which of the following instructions should the nurse give to the client prior to the procedure? A. Battery All these clients have a GI problem. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. 1. TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . Temporary urinary retention (common for clients to develop after removal), 90. 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. Review a low-sodium diet for a client with hypertension. c. Foot Place in priority order. 4. Incorrect: This prescription is written correctly. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. The client is reporting anxiety, discomfort, and a feeling of bloating. a. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. The client can indicate desire for Do Not Resuscitate (DNR). 5. c. Shivering 2. This task cannot be delegated to the LPN/LVN. Make nursing assignments appropriate to the skill level . Client to receive dietary education. When staff do not feel vested in any new process, there is a sense of underappreciation. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. a. What is the most appropriate action by the charge nurse? This includes medication enemas. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. c. I'll bear weight on my ankle for 10 minutes every hour 1. A charge nurse is planning client activities for the day. A nurse is engaging in relationship counseling with a male client. 1. 3. 2. When a family member asks how respite care can help, which of the following responses should the nurse provide? b. 5. Which tasks should the charge nurse delegate to the nursing assistant? 1. The third client that should be assessed by the nurse is the client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. The nurse is using which of the following therapeutic communication techniques? A nurse asks a client to share personal stories. d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. Which of the following instructions should the nurse include? The nurse should assess the client for which of the following expected outcomes after catheter removal? 1., 2., 3., & 4. Which of the following actions should the nurse take? d. Discussing intake and output Obtain a client's consent A nurse is caring for a client who has a mental health disorder. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. (Select all that apply.) a. The charge nurse should notify the nursing supervisor who will seek additional staff. is a new graduate in orientation. Which of the following actions should the nurse take? Request a prescription for a medication to ease the client's anxiety 2. 1. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. -Review a low-sodium diet for a client who has HTN Discuss the competency of the surgeon Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. 2. 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. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Drag and Drop the items from one box to the other. 5. What task would be best to assign to the LPN/LVN? 3. Teaching insulin self administration to a diabetic client. Did you think dehydration and fluid volume deficit? A nurse who is on hormone replacement therapy. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. Well, do you see the q.d.? What is the best response by the charge nurse? b. Monitor for GI upset 30 minutes after meals. d. Talk with others who have info about the client, b. I can detect the presence of carbon monoxide by a metallic odor, 58. Incorrect: Atrial fibrillation places the client at risk for blood clots. 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. 5. Nursing questions and answers. 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. A client on a surgical unit frequently quarrels with the staff. d. Motor impairment, 84. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. a. c. Malpractice A medical-surgical LPN has been sent to a short-staffed pediatric unit. b. c. Providing anticipatory guidance to a client in crisis c. Face shield C-section planning discharge, postpartum infection, mastectomy. When asking the client about his receptiveness to the transfer 3. A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Even though the client is a child, superficial burns require only dry sterile dressings and possibly oral pain medication, both tasks which are within the scope of practice for an LPN. This action is a defensive intervention, and does not address the quarrelsome behavior. This is an appropriate and safe action for the unlicensed nursing assistant to do. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. 1. A nurse is caring for a client who is postoperative. d. Remove and reinsert the NG tube, a. b. Wash the area of the puncture thoroughly with soap and water There is a trailing zero after the prescribed dose. 2. 1. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. 1. c. We administer all medications intravenously to clients in this unit Change the subject when the client behaves defiantly 2. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. d. Services are centered in long-term care facilities, a. Notify the charge nurse of the observations. The nurse voices his concern to the charge nurse. 5. c. I will inspect my crutches everyday for signs of wear Which of the following should the nurse identify as an interpersonal variable? Which client should the nurse see first? A nurse is caring for a client who has a hip fracture that requires surgical repair. Select all that apply d. Water heater temp 54.4 C (130 F) c. Palpating for pedal edema Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. A nurse is orienting a new assistive personal (AP) to the unit. 3. This is normal for clients with hemorrhoids. Which of the following statements should the preceptor make? A nurse is caring for a client who is postoperative following an appendectomy. Tenderness over the symphysis pubis 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. Which of the following actions is the priority for the nurse to include in the client's plan of care? (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. 4. 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. A nurse is caring for an older client who is at risk for skin breakdown. A nurse is teaching a client about carbon monoxide poisoning. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. Accept the client's behavior as confrontational. A client who is disoriented and awaiting transfer to a long-term care facility. Which of the following infection-control precautions should the nurse use caring for this client? Client who is a diabetic experiencing diabetic neuropathy. Once the client is stable, the UAP could perform this task. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. Correct: Did you notice the hint? 3. A nurse is having difficulty caring for a client due to variables affecting the communication process.
a charge nurse is making client care assignments
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