1. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. The nurse should not lecture, scold or argue with the float nurse. Place the pack on a sterile work surface The charge nurse must triage and assign clients to appropriate staff. 4. Which of the following physiological responses to prolonged immobility should the nurse expect? Doing this at the end of the shift could prevent completion of the client assignment sheet for the next shift and possibly create unnecessary overtime for the charge nurse. 1. An adult (18 years or older) can create an advanced directive. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. c. Notifying the provider of physical exam findings 4. It happened so long ago - just get over it!" c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). Incorrect: The concern here is the client being fed their meal. 2. Incorrect: The RN is responsible for developing the plan of care which would include necessary referrals. This would be out of the UAP's scope of practice. b. c. Review another client's similar surgical experience This service began with the client's admission to the hospital, 18. d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. a. I wish I didn't have to attach the electrodes to my skin Select all that apply. 4. A client with diabetes admitted for debridement of a foot ulcer. a. The client should be assessed first to rule out respiratory difficulty and hemorrhage. b. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. Prepare a list of clients who could quickly be discharged or transferred. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. b. eminent The report should contain consequences. 3. d. Talk with the client's partner, b. Make nursing assignments appropriate to the skill level . 2. The other options may be correct but are not the best first action. d. Motor impairment, 84. However, there are some basic points which are standard among all facilities. 2. A charge nurse is making client care assignments. Incorrect: Moistening the dentures will ease insertion. Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. A. 1. Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. 3. Clients over the age of 65 must have a saline lock according to facility policy Refuse the delegated intervention. b. I will begin once the client's discharge order is written Incorrect: This again is assessment which is the role of the RN only. A nurse is teaching a client who has a history of falls about home safety. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a c. Leave a nightlight on in the client's room Provides day to day direction and supervision to assigned direct patient care staff. Symbolic communication The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Remove all metal necklaces a. Incorrect: This would unnecessarily alarm the clients. 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. Making client care assignments As the RN charge | Chegg.com Science Nursing Nursing questions and answers Making client care assignments As the RN charge nurse, you are preparing to make assignments for the oncoming shift in the medical-surgical unit. *HURST REVIEW Qbank/Customize Quiz - Leadership 4. Richied5864 Richied5864 . b. b. Assigning tasks to an AP b. c. Environment 3. b. Tenderness over the symphysis pubis 3. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Use the tablet's packaging to pick it up from the counter butter, which contain 16 g of protein, 7 g of carbohydrates, 1. 5. d. Anger, b. Simply accept the assignment since overtime is mandatory. 4. Encourage clients and families to develop mutually appropriate visitation times. Something new could have occurred with the clients, making the assignments too heavy. A nurse is preparing to move a client who is only partially able to assist up in a bed. d. Lean back in the chair, b. Complete a client assignment sheet for the oncoming staff. 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. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. a. A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. a charge nurse is making client care assignments for the day. Which of the following statements should the nurse identify as an indication the client needs further teaching? A client diagnosed with rheumatoid arthritis needing discharge teaching. Remember, pick the killer answer first! Decreased or suppressed respiration are priority. 7. 3. 6. This documentation should go to your manager. d. Determine if the client uses hearing aids, b. There is a possibility that a hypothermia blanket may be prescribed. This client is likely in metabolic acidosis due to diabetic ketoacidosis (DKA). b. 1. b. 4. What is the appropriate assignment? 5. Use adult diapers to prevent frequent clothing changes 1. Occupational therapist M4 Client Care Assignment.pdf - Making Client Care d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? c. One nurse lifting the client's legs as the client uses a trapeze bar Which of the following instructions should the nurse include? a charge nurse is making client care assignments for the day. which Which of the following explanations should the nurse provide? A nurse is developing a plan of care for a client who does not speak the same language as the nurse. 2., 3. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. Drag and Drop the items from one box to the other. On an ongoing basis, the charge nurse evaluates individual and collective outcomes of the patient care provided during their shift, compares patient care delivery to accepted standards, adjusts assignment of resources as necessary, and reports changing needs and outcomes to the health care staff. A nurse caring for a client is using active listening skills. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. Practice Leadership Exam for Nursing - A charge nurse in an - StuDocu a. Hypotension Which actions should be instituted by each unit's charge nurse? This service focuses on teaching the primary caregiver to meet the client's needs A nurse is performing care activities for a client in the zone of touch that requires his consent. 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. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? c. Offering false reassurance 2. 2. A nurse who is 10 weeks pregnant. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. The third client would be the one needing a dressing change. b. I will come back later and we can talk d. 216, 22. This could cause a medical emergency. Which referral would most likely be appropriate for the nurse to make? Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. A charge nurse is making client care assignments. a. The nurse chooses to confront the client. a. I'll apply ankle to my ankle today and tomorrow The nurse should perform which of the following activities in this space? Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. This is an appropriate prescription. Which of the following findings indicates that the client is meeting this goal? A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Allow the UAP to work without supervision. Select all that apply 1. . This is a task that can be delegated to the LPN/LVN. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. Occupational therapist (an occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding). c. I'll wear low heeled shoes from now on 1. 3. Select all that apply Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. 3. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) 4. Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. 1. Accept assignment, documenting personal concerns regarding work conditions. The charge nurse's best response is to first obtain the needed information to make the best decision. The client was lying on the floor next to his bed (nurse should document what they actually see), 68. 1. a. Clarifying Select all that apply Documentation of what occurred, and the client's assessment is required in the nurse's notes. The nurse does not know the skills of the new UAP. Reach around the pack and open the top flap away from the body 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. 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. 3. b. Write N next to the nonessential clauses and E next to the essential clauses. No! Determine caregiver's stress level and coping strategies. Wrapping the dentures in tissue while the client sleeps Teaching insulin self administration cannot be delegated to the LPN. 4. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Ask the charge nurse to evaluate the intervention. 3. "Please explain what you mean by the word 'nervous'.". A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. Which of the following RNs should not be assigned to this baby? The nurse is using which level of communication at this time? Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Encourage the client to use self-exploration Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. d. I will place a bath seat in my shower to use when I bathe, b. Which of the following info should the nurse include? Besides yourself, there are the following staff: Your unit has 12 beds. Therefore, this would not be the most appropriate nurse to assign to this client. Everyone knows there are others who can chair this committee better than me Which tasks should the charge nurse complete at the end of the shift before leaving for the day? b. b. Irrigate the NG tube with 100 mL of sterile water b. What proposal would the nurse determine to best meet the needs of families and clients in long term care? Which task should the nurse take responsibility for completing? A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. which of the following actions should the nurse perform? 3. c. The client's culture Which of the following responses should the nurse make? Nursing questions and answers. Which of the following client statements indicates an understanding of the procedure? Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Incorrect: The nurse is responsible for monitoring a client. Assist a client to ambulate using a gait belt. The RN with 2 weeks' experience on the postpartum unit. The healthcare team should recognize the client as the center of the team. d. I will begin once the client's insurance company approves discharge coverage, b. d. Do you think crying will help? Refuse the overtime assignment, being prepared for disciplinary action. 1. Write the letter of your choice on the answer line. -Review a low-sodium diet for a client who has HTN Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Send a day's worth of medications with the client to the receiving facility. a. Auscultating heart sounds The nurse received a client following surgery 8 hours ago. 4. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. When a family member asks how respite care can help, which of the following responses should the nurse provide? Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. The charge nurse on the postpartum unit is making assignments. 1., 2., 3., & 4. This will allow the charge nurse to analyze the situation to make a better decision as to whether the assignment should be changed. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. b. Perform the Heimlich maneuver 3. The charge nurse identifies that three admissions were received during the night shift, one nurse has called in sick, and the clients on the unit have high acuity levels. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Notify the primary healthcare provider. Speak using his usual tone of voice Initiate oxygen and IV lines as needed. 4. 3. What is the best response by the charge nurse? c. Offer the client personal thoughts and beliefs d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. 3. They are likely to wait for others to initiate conversation 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. e. Feed a client who had a stroke 3 months ago, 31. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. A client receives a wrong medication. b. I'll rewrap my ankle starting from the knee down 4. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. 2. Incorrect: If alcohol or drug dependency is suspected, confrontation will result in hostility and denial. The situation should be explored before bringing the supervisor in on the situation. The nurse is responsible for the assessment of all vital signs of post-op clients. b. 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. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Correct: Nurses must use and recognize appropriate terminology and abbreviations to avoid potential client harm. Remind the client to avoid tight fitting clothes. Elderly clients have special fluid and electrolyte issues after a fall. a. Which of the following tasks should the nurse delegate to AP? Feed the client after warming the food. As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. 4. d. Proceed with the preparation of the patient's surgical procedure, 15. 1. 1. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. Channel is a new graduate in orientation. The key word in the stem is first. Lisinopril 20.0 mg PO daily 8. 10. American Sickle Cell Anemia Association 3. Photo comes from the Greek word for light. Which of the following types of communication breakdown does this response represent? 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. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day 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. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. Which of the following actions should this nurse take? Point out inconsistences in the client's behavior (a nurse using confrontation helps the client become aware of inconsistencies in his feelings, attitudes, beliefs, and behaviors. with this question, the nurse is using which of the following communication techniques? 4. Assign more daily tasks to the UAP. Tenderness over the symphysis pubis 5. a. This client should report an improved respiratory, not shortness of breath. d. The nurse has already considered alternatives to restraints, a. B. Incorrect: This prescription is written correctly. a. 3. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours . Which of the following statements should the nurse make? 4. Incorrect: There are situations in which the LPN must notify the primary healthcare provider. The client then states, "I have changed my mind and do not want to have the procedure done." c. There is fluid leaking around the insertion site Splitting the overtime shift is an acceptable option that the nurse could suggest in order to solve the staffing problem and decrease the amount of time the nurse will be working. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. 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. Client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. a. b. But the client does need to be assessed prior to the client with Crohn's disease who is improving. c. Decreased sodium excretion The nurse is caring for four clients. b. Negligence c. Raised toilet seats Because facilities generally prefer some type of consistent schedule for staffing purposes, older visitation policies were often very restrictive. 4. ESSENTIAL FUNCTIONS: Provide the best possible nursing care by planning, organizing, and directing the nursing functions of patients in the unit. Left upper forearm Limit the client's fluid intake in the evening b. b. Gather supplies to prepare room for isolation. 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. Warm the feeding solution to the body temperature Correct: Communication is important in delegation, as is follow-up. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. 1., 2., 4., & 5. Which of the following info should the nurse include? Which action by an unlicensed nursing assistant would require the nurse to intervene? 1., 2., 4., & 5. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Increased insulin production 4. A nurse has completed an informed consent form with a client. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. b. Verbalize understanding of how the client feels Which of the following actions should the nurse take to assist the client with feeding? c. Rephrase statements the client does not hear 1. a. Auscultate breath should at least ever 2 hr a. Denial (a) HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010\mathrm{HCN}(a q)+\mathrm{H}_2 \mathrm{O}(l) \longrightarrow \mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{CN}^{-}(a q); K=4.9 \times 10^{-10}HCN(aq)+H2O(l)H3O+(aq)+CN(aq);K=4.91010 1. Teaching about a medication Ask for any staff objections to rearranging work hours. 1. 2. They are more direct when discussing issues (men focus on issues and discuss them more directly and readily than women do), 20. a. Provides day to day direction and supervision to assigneddirect patient care staff . Which of the following tasks should the nurse delegate to assistive personnel (AP)? Gown c. Foot An LPN/VN has been floated to the emergency room following a chemical plant explosion. Convenience for the nursing staff or the client's family There are a total of 10 adult clients. A nurse is teaching a client about the physical effects of chemotherapy. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. This stage is when testing occurs to identify boundaries of interpersonal behaviors Show client who has conjunctivitis how to clean the eyes. A nurse is caring for a client who has a wound infection. 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. A nurse is caring for a client within the intimate zone of the client's personal space. c. I'll bear weight on my ankle for 10 minutes every hour 4. 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. a. Which clients would be appropriate assignments for the LPN/LVN? c. Hallucinations at the onset of sleep 2. An Advance Directive includes a Living Will and a Medical Power of Attorney. Gathering needed equipment and supplies is within the scope of duties for the UAP. A nurse is caring for a client who has emphysema and has difficulty with mobility. Client diagnosed with hemorrhoids who had some spotting of bright red blood on toilet tissue with last bowel movement. 1. Incorrect: This client does not have a predictable outcome. Battery b. e. Feed a client who had a stroke 3 months ago, 32. a. Request a prescription for a medication to ease the client's anxiety Patient safety must remain the priority. Which client should the nurse assess first? b. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. The surgeon initially prescribes a clear liquid diet. Assist ait to ambulate using a gait belt. Removing the client's dentures 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. Providing hygiene care to a client who is HIV positive The charge nurse might not have realized all the responsibilities of taking this team of clients. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage 6. Therefore, this client needs the advanced assessment skills of the RN and should not be assigned to the LPN. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. c. The restraints should promote the client's safety and prevent injuries These individuals are selected by the charge nurse, and do not have to be nurses. A medical-surgical LPN has been sent to a short-staffed pediatric unit. To focus on effective learning with this client, which of the following interventions should the nurse use? b. Therefore, this client would not be a priority over a client who may be experiencing a MI. c. Blood-tinged urine d. I shouldn't advice you about what is ultimately a personal decision, b. Empty the drainage bag at least every 8 hrb.) Dr. Frankenstein had seen himself as a(n) ?\underline{? a. Provide an adaptive feeding device for the client, 50. c. Inform the surgical team to cancel the client's surgery d. When asking if the client took his medications this morning, 82. One nurse lifting as the client pushes with his feet d. Request a prescription for an indwelling urinary catheter, c. I will begin upon the client's admission to the facility (effective discharge planning must begin upon admission of the client to the facility), 60. 1. c. I will make sure my visitors smoke outside The client with cystitis is stable and has a predictable outcome. 208 b. d. Highly concentrated urine, 91. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Anyone over age 18 can have an Advanced directive. & 4. Both of these clients are terminal. The LPN should refuse the intervention. 1. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. This should not be delegated to the LPN/LVN. It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. There is a trailing zero after the prescribed dose. c. Discard the tablet and obtain another dose of medication Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? assignmentcafe.com - A charge nurse is making assignments for nursing b. Massage any bony prominences to promote circulation 3. c. Do not eat or drink anything the morning of the test c. Gender This situation is considered an external disaster which means the hospital will be expecting multiple victims. b. Dons gloves to empty a urinary drainage device d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Nothing life threatening. Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. Perform catheterization when you recognize the urge to void It can result in muscle spasm and tissue damage. Talk to each nurse about concerns related to assigned clients.