b. Pain Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Symbolic communication There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. 2. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. Incorrect: The nurse retains the responsibility for the delegated task. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. d. Perception Incorrect: The client will need IV access for sedation during the procedure and will need the fluid for hydration since the client is NPO. Include any relevant statements the client made about the ulcer A client with atrial fibrillation currently on a diltiazem drip. 5. Nurses Report Sheet Template Nicu. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. 1. Encourage clients and families to develop mutually appropriate visitation times. The nurse voices his concern to the charge nurse. The client with cystitis is stable and has a predictable outcome. Which of the following items should the nurse include on the lunch tray? 4. 3. the nurse responds: "It must be very frustrating to encounter this kind of attitude." 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. 1. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? Incorrect: If a report is made to the BON, it should be a factual documentation of specific events and actions, not a statement of impairment. b. c. Changing a dressing, 78. (Select all that apply.). 2. An increased temperature will have a direct effect on the brain's metabolism and function. The nurse is caring for four clients. A nurse is admitting a client who has a partial hearing loss. Of my three brothers and sisters, my sister Giselle has the best sense of humor. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. b. Wash the area of the puncture thoroughly with soap and water Which of the following actions should the nurse take? Which of the following statements should the nurse make? 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. d. Left forearm, b. Incorrect: Obtaining the urinary output of a client at the end of the shift is appropriate for the nursing assistant and should be documented and reported to the RN. The client receives home health care and spends most of his day in a reclining chair. 1. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? 2. 2. 3. 2. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. c. Notify the nurse manager Correct: Traction should never be relieved without a primary healthcare provider's prescription. d. Do you think crying will help? Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. a. b. Incorrect: The charge nurse does not have to assess every client. Client reporting a headache and has a fruity breath. The charge nurse might not have realized all the responsibilities of taking this team of clients. 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. The best practice committee utilizes current research in their recommendations. a. 2. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. Compartment syndrome could be developing which can impede circulation and cause nerve damage. The third client would be the one needing a dressing change. A nurse is teaching a client about carbon monoxide poisoning. Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. Twist at the waist when she moves an object to one side Nothing will get passed the complete blockage. Select all that apply. Teaching insulin self administration to a diabetic client. c. One nurse lifting the client's legs as the client uses a trapeze bar Which of the following indications should the nurse include? 1, 3 & 5. A nurse is providing discharge teaching for a client who requires home oxygen therapy. A nurse is caring for a client who is postoperative following an appendectomy. 3. Which task would be appropriate for the nurse to assign to an LPN/VN? Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Ambulating a client who is 2 days post vaginal hysterectomy A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. All these clients have a GI problem. This is normal for clients with hemorrhoids. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. Right forearm Which response by the LPN is appropriate in response to the inappropriate delegation? 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. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. The nurse asks why the client needs to know this. 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. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. Send a day's worth of medications with the client to the receiving facility. Which referral would most likely be appropriate for the nurse to make? b. a. Which of the following findings indicates that the client is meeting this goal? Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. 5. Client scheduled for a dressing change to foot ulcer. 2. A nurse who is on hormone replacement therapy. c. Gender Perform range of motion (ROM) exercises at least 2-3 times daily A client requesting assistance packing his belongings for discharge later today., In what order should the nurse see the clients? Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. Removing the client's dentures 3. Measure urine output when client voids. a. Transpersonal b. Intrapersonal c. Interpersonal d. Public b. Normally, red blood cells are flexible and round, moving easily through blood vessels. c. Initiate a liquid diet for the client c. I should purchase a carbon monoxide detector for my home Explain oral hygiene to a client receiving chemotherapy The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. 4. a. Broth Notify the surgeon that the client wishes to withdraw informed consent for the procedure Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. 1. b. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. 3. What would the approximate meaning of photoelectric be, based on these root words? a. Which of the following nontherapeutic communication techniques is the nurse using? The last client that should be sent back for care is the client experiencing epigastric pain and nausea after eating. Discussing a client's surgical procedure with the nurse manager Plan all care to be completed in early morning to allow afternoon for visitation. Which of the following responses should the nurse make? 4. A nurse instructs a female client about collecting a midstream urine sample. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. The RN requests reassigning at least one of the clients to another nurse. 3. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Occupational therapist Determine caregiver's stress level and coping strategies. 1. A goal for this client is to use proper body mechanics at all times. 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. c. Provide the client with a diet high in protein Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. 1. Which actions should be instituted by each unit's charge nurse? Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. Electric cords behind the furnitrure 2. Change the subject when the client behaves defiantly b. I will begin once the client's discharge order is written Therefore, the RN must perform this task and cannot delegate this to the LPN/LVN. Select all that apply. Client reporting epigastric pain and nausea after eating. 2. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). The nurse cannot allow the UAP to perform advanced tasks. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Which of the following actions is the priority for the nurse to include in the client's plan of care? A nurse is caring for an older client who is at risk for skin breakdown. one of the licensed practical nurses Get the answers you need, now! b. c. Hold an object away from her body as she lifts it This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client. b. I'm so sorry to hear about this d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) (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 Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. 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. A nurse receives a client care assignment from the charge nurse that he believes is unfair. Place in priority order. A float nurse arrives on the unit to assist in the care of clients for the shift. 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. Which of the following instructions should the nurse give to the client prior to the procedure? 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 & 6. 2. Which nursing intervention should the charge nurse implement? The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. c. imaginary Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. 2. Place the client in low Fowler's position A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Clients over the age of 65 must have a saline lock according to facility policy c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? Alcoholic Anonymous Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. 3. This stage is when testing occurs to identify boundaries of interpersonal behaviors 3. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. A client requesting assistance packing his belongings for discharge later today.. Witness the client's signature Documentation of what occurred, and the client's assessment is required in the nurse's notes. Collecting I & O totals for unit clients at the end of shift. 3. The healthcare team should recognize the client as the center of the team. The client would develop severe cramping. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. Lumbar puncture reporting a headache. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. This should not be delegated to the LPN/LVN. The nurse has received the change-of-shift report. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? 2. 3. c. Notifying the provider of physical exam findings Which action by an unlicensed nursing assistant would require the nurse to intervene? b. A family member requests that the nurse apply restraints. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. 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. Have another nurse finish preparing the medications & 4. 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. The third client that should be sent back for treatment is the female client stating she has been raped. This includes medication enemas. c. The emphasis is on the client's complete recovery from the illness or injury Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). One important aspect is encouraging the flow of ideas between management and staff members. d. I have a set of my brothers' crutches in the basement I can also use, a. Try different methods of oral care on unresponsive clients to see what works best. But the client does need to be assessed prior to the client with Crohn's disease who is improving. a. Limit the client's fluid intake in the evening 3. -Review a low-sodium diet for a client who has HTN 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. c. Use an aggressive tone of voice a. Elevating the head of the bed 30- 40 for the client post thoracotomy d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? 1. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. Review the action of insulin therapy 3. This is a diabetic clinic. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. b. 1. Handoff and Nursing Report Sheet. Measuring vital signs Provides day to day direction and supervision to assigneddirect patient care staff . Select all that apply 4. 1. 4. Incorrect: This would unnecessarily alarm the clients. Which group of clients should she assign to the medical surgical nurse? The charge nurse on each unit needs to prepare a list of possible discharges or transfers to be given to the appropriate primary healthcare providers for further action. Feedback Incorrect: The client does need to be cleaned out below the tumor so that the primary care provider can see the area of concern and complete the biopsy. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? The option does not say the client is terminal, in a vegetative state, or in a coma. A cardiac step down unit has requested float staff because of multiple impending admissions. 2. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Incorrect. INCORRECT: There is no information regarding how recent was the surgery or the degree of pain being experienced. 1. b. 2. 2., 3. 4. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". 3. Client prescribed antibiotics for cystitis. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. 212 This protein is released by cells in the stomach. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. a. The LPN/LVN can gather data, but the RN is responsible for validating and interpreting that data to assess and evaluate. b. eminent 1. They are likely to wait for others to initiate conversation 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.