A nurse is providing discharge teaching for a client who requires home oxygen therapy. 4. Gather and apply dressings to open wounds. c. Palpating for pedal edema c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. The nurse should not assume that the UAP just did not do their job, but needs to ascertain the reason for not feeding the client. Which of the following actions should the nurse take prior to administering the tube feeding? This is the most stable of the four clients which places this client last to be seen. 4. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. Client to receive dietary education. Incorrect: This again is assessment which is the role of the RN only. Assign a nursing assistant to help the client with self-care activities. This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 3. d. I shouldn't advice you about what is ultimately a personal decision, b. Female client stating she has been raped. Besides yourself, there are the following staff: Your unit has 12 beds. Remember, pick the killer answer first! 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. Which of the following communication techniques should the nurse use during this phase? It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. 4. Determining the client's length of stay A home health nurse is conducting a home safety assessment for an older adult client. This individual should be provided appropriate comments of appreciation for this accomplishment. d. Do you think crying will help? Which of the following actions should the nurse take regarding informed consent? d. Move to the opposite side of the pack and open the fourth flap, 54. Which referral would most likely be appropriate for the nurse to make? Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Explore the client's feelings Solved 4. A charge nurse is making client care assignments. | Chegg.com c. Gender Draining the colostomy bag on a client with diarrhea. The surgeon initially prescribes a clear liquid diet. }? benefactor of the world. a. Bathe a client who had an amputation 2 days ago 4. c. Distended bladder d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) This schedule may leave some clients too exhausted to visit with family. A nurse is assessing a client who is experiencing prostatic hypertrophy. 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: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. 1. The infusion rate has stopped but the tubing is not kinked 4., & 5. 2) Assist a client to ambulate using a gait belt. The client is apparently stable and does not require any advanced assessment skills or specialized care. 1. d. Assault, b. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? 2. The nurse who made the medication error should take which of the following actions first? Perform range of motion (ROM) exercises at least 2-3 times daily e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. "The client is weak on the right side, so please assist the client with dressing . A client with atrial fibrillation currently on a diltiazem drip. Place the pack on a sterile work surface Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. b. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. b. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. 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. 2. Report of feeling pressure Aplastic anemia is a rare but serious condition. When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. Allow families unlimited visitation around the clock to meet their schedules. A distance of 5.00 cm is measured between two adjacent nodes of a standing wave on a 20.0-cm-long string. Which of the following actions should the nurse take? d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. This task cannot be delegated to the LPN/LVN. 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. (Select all that apply.) Which of the following client statements indicates an understanding of the procedure? Estimate the number of Calories in two tablespoons of peanut So, now you must decide which of these high priority clients should be seen in what order. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Ask the charge nurse to evaluate the intervention. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. This could cause a medical emergency. b. The responsibility of the nurse manager is to implement change in a positive manner, while assisting staff adaptation even to unpopular modifications. Although this will require assessment, this client is not the priority at this time. This includes medication enemas. Printable Nursing Brain SheetPrintable Nursing - soyu.caritaselda.es Correct: An LPN should be assigned clients with predictable outcomes. Select all that apply. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. 3. Which clients could be assigned to an LPN? The nurse received a client following surgery 8 hours ago. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 3. Dentures should be stored in a denture cup. Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. When determining if the client is eating a well-balanced diet The body needs vitamin B12 to make red blood cells. b. I'll do exercises that strengthen my abdominal muscles A client who is disoriented and awaiting transfer to a long-term care facility. A nurse is performing care activities for a client in the zone of touch that requires his consent. b. a.) The charge nurse on the postpartum unit is making assignments. Handoff and Nursing Report Sheet. Place the client in low Fowler's position a. I will begin 48 hr before the client's discharge Which task would be appropriate for the nurse to assign to an LPN/VN? A cardiac step down unit has requested float staff because of multiple impending admissions. d. I have a set of my brothers' crutches in the basement I can also use, a. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Temporary urinary retention (common for clients to develop after removal), 90. 3. This assumption is not appropriate, and the feelings and concerns of the client should be addressed. It happened so long ago - just get over it!" 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. 4. Warm the feeding solution to the body temperature Provides day to day direction and supervision to assigneddirect patient care staff . 2. Notify the charge nurse of the observations. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. 1. A client has been admitted with folic acid deficiency anemia. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. LPNs can provide the client with needed analgesics or may simply guide the client with diversional activities for managing this type pain. Sudden attacks of sleep Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Pick up the tray and tell the UAP that they didn't do a good job. a. 4. 5. c. Respite care helps relieve pain and promote comfort Decide which choice fits best in the blank. 1. A nurse is working with an assistive personnel (AP) to There are a total of 10 adult clients. The charge nurse might not have realized all the responsibilities of taking this team of clients. They have found my address and are coming for my family!" b. Donation costs are the responsibility of the donor's family and estate However, it remains true pain for this client and the client would need intervention to help manage this pain. 1. 1., 2., 4., & 5. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. The RN with 2 weeks' experience on the postpartum unit. c. Explore the client's feelings about dietary modifications c. I'll need to shave the hair off the skin where I place the electrodes The client asks the nurse, "Why do I need that? 1. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Nothing life threatening, but an assessment needs to be made regarding the ulcer. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. Client with ureterolithiasis who requires frequent PRN pain medication. The RN requests reassigning at least one of the clients to another nurse. Speak to the UAP to determine what happened with the feeding. 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. Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. It is within the LPNs scope of practice to administer antibiotics. 1. d. Wait to discuss the behavior in the presence of others, a. 4. The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. Vital sign measurement e. Throw rugs, 40. & 3. 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