a charge nurse is making client care assignments

A charge nurse is making client care assignments. 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 nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. This client could be transferred with traction still maintained. Based on the information provided in report, which client condition should be the nurse's priority? 4. b. Aplastic Anemia Support Group. Placing a washcloth in the bathroom sink prior to cleaning. A charge nurse is making client care assignments. Offer to take one of the clients. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. The nurse prefers to check all vital signs on all clients. This determination is needed to assure client safety is being considered. d. Highly concentrated urine, 91. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. Which action by an unlicensed nursing assistant would require the nurse to intervene? c. Helping the client into the shower 3. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. c. Measurement of residual urine after urination What actions should a nurse take to provide continuity of care when discharging a client diagnosed with hemiparesis to a long-term care facility for rehabilitation? What is the appropriate assignment? 2. 1. Following a large hurricane, multiple clients arrive at the emergency room for treatment. 2. a. Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. d. Let's wait until tonight to see if he continues his behavior, 63. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? c. The client's culture b. The spouse can rescind the Advance Directive if the client becomes unresponsive. There is a possibility that a hypothermia blanket may be prescribed. Restock pediatric patient care rooms with oral rehydration fluids using a standardized check list., The charge nurse is preparing the patient care assignments for the day shift, assigning clients to a LPN/LVN and a certified nursing assistant (CNA). Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. 4. Encourage the client to use self-exploration c. Inform the surgical team to cancel the client's surgery Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. Send a day's worth of medications with the client to the receiving facility. b. d. Respite care is a continuation of psychological support after a family member dies. Select all that apply. There are a total of 10 adult clients. c. When asking the client how he completes his ADLs c. Assist the client to the floor and begin mouth-to-mouth Which task is appropriate for the nurse to delegate to the experienced nursing assistant? A nurse is teaching a client who has a history of falls about home safety. Observe the client before taking further actions A float nurse arrives on the unit to assist in the care of clients for the shift. 4. 1. A school-aged child with a fractured femur who is in balanced suspension traction. a. I'll urinate a little then stop PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? Client one day post kidney transplant. Which of the following tasks should the charge nurse reassign to a licensed nurse? 4. Taking the report from the ED could be delayed but is a courtesy to the ED and will provide information about the client that will be useful in making assignments for the next shift. Which of the following statements should the nurse identify as an indication that the client understands the discharge information? This is outside the scope of practice for the LPN/LVN. If the client is unstable, the nurse would retain the role of measuring the vital signs. The nurse is focusing on which of the following elements of the communication process? 2. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. d. Counting radial pulse When a family member asks how respite care can help, which of the following responses should the nurse provide? A client receives a wrong medication. Vital sign measurement Which of the following findings should the nurse expect? a. d. Message, 67. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. The nurse could definitely be part of the committee. b. Provide an adaptive feeding device for the client, 50. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. b. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? 1. The LPN/LVN can reinforce teaching. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. It can result in muscle spasm and tissue damage. He charge nurse is making client care assignments for the evening shift. Decreased or suppressed respiration are priority. This is an appropriate prescription. a. Notify clients that the disaster plan has been put into effect. Ask for any staff objections to rearranging work hours. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. 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. A nurse is discussing the norming stage of the group development process with a student nurse. 6. Encourage the client to be more cooperative. Incorrect: By encouraging the client to be more cooperative, the nurse is denying the client's feelings and concerns. Which of the following instructions should the nurse give to the client prior to the procedure? 3. 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). a. c. I will place an area rug at the entry of my bathroom c. Hallucinations at the onset of sleep Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. 2. Ask the RN why the assignment is too heavy. 3. The area surrounding the insertion site feels warm to the touch, 61. d. 216, 22. Select all that apply. A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. c. Open the right flap with the left hand When the licensed person cannot determine this, the task should not be delegated. d. Services are centered in long-term care facilities, a. This is a diabetic clinic. 3. Which of the following items should the nurse offer the client? c. Distended bladder Involve the client in their plan of care. a. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. 2. b. Numbness (Select all that apply) 3. b. Irrigate the NG tube with 100 mL of sterile water Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. d. Motor impairment, 84. a. Focus on the client's present circumstances instead of his personal stories 7. d. Social conversation, a. 4. It is not a routine task. The client says, "go away, no one can help me." Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. b. 5. A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. a. A nurse enters an older adult client's room to insert a saline lock. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? A client requesting assistance packing his belongings for discharge later today., (Select all that apply.). Which prescription should the nurse question and have corrected? 3. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Which of the following tasks should the nurse delegate to assistive personnel (AP)? leadership management of care nurse on unit is providing care for group of clients. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Remind the client to avoid tight fitting clothes. Elderly client admitted 30 minutes ago with reports of constipation for four days. 2. A nurse is preparing medication for a client when another client has an emergency. c. Request a tray without pork (Select all that apply.) b. It is the primary healthcare provider's role to receive acceptance for transferring a client to another facility. A list of current medications is sent to the facility. b. Grape juice b. I will bear the weight of my body on my hands 3. 1. and 16 g of fat. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. d. Sleep apnea Select all that apply 5. 5. All these clients have a GI problem. Female client stating she has been raped. This client will also need a lot of education regarding anti-rejection medications. The LPN can monitor the wound and provide care to the PEG insertion site. This is the most stable of the four clients which places this client last to be seen. Which clients would be appropriate assignments for the LPN/LVN? Pain The client asks the nurse, "Why do I need that? 2. 2. b. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? An increased temperature will have a direct effect on the brain's metabolism and function. Which of the following should the nurse include as a criterion for applying restraints? Initiate oxygen and IV lines as needed. c. Shivering (shivering is a systemic response to cold therapy as the body attempts to promote heat production), 77. A lack of rapid eye movement (REM) sleep Speak to the UAP to determine what happened with the feeding. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. In planning care for the post-operative client, the nurse has decided to retain the task of vital sign assessment. 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. a. A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. 1., 4., & 5. Correct: This client is at risk for respiratory depression caused by morphine and should be assessed. Nothing by mouth (NPO). Since the enema would clean below the obstruction, the client would be able to expel the enema and any feces in this part of the colon. Correct: Traction should never be relieved without a primary healthcare provider's prescription. Which of the following methods should the nurse plan to use? Channel 3. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. 1. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. 6. This service began with the client's admission to the hospital, 18. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. 2. Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. The nurse caring for the client at the time of death requests organ donation d. Assault, b. Incorrect: The client does need to have food; however, there is another action that should be performed first. b. the nurse responds: "It must be very frustrating to encounter this kind of attitude." 2. Which of the following RNs should not be assigned to this baby? d. principal. 3. The nurse has another priority. 2. Incorrect: While it is true that the nurse manager is ultimately responsible for implementing and announcing new schedule changes, doing so without any staff input can create discontent in the work environment. 3. Licenced practical nurses are a little less educated than registered nurses. C-section planning discharge, postpartum infection, mastectomy. 1. b. The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Incorrect: Is phantom pain something that is unexpected with above the knee amputations? A nurse is planning care for a female client who has an indwelling urinary catheter. Checking capillary refill beneath the client's fingernail d. I'll use each cleansing wipe twice, d. I decline this opportunity at this time (assertive because it contains an "I" statement and it is clear and firm), 52. e. Feed a client who had a stroke 3 months ago, 32. a. I'll apply ankle to my ankle today and tomorrow Hanging a new bag of total parenteral nutrition (TPN). Incorrect: There are situations in which the LPN must notify the primary healthcare provider. 5. A nurse is working with an AP while caring for a surgical client who is 1 day postoperative. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. Have a pen and paper handy Which of the following responses should the nurse make? It's unfortunate that I have to be in the hospital for this treatment d. Establishing the client's secondary medical diagnoses, b. A client with diabetes admitted for debridement of a foot ulcer. The client's self-report of pain severity, 88. 3. 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. a. Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. 2. 2. Respite care allows the primary caregiver time away from day-to-day care responsibilities Both of these clients are terminal. 2. a. 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. There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. Based on this information,what should the nurse do? The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. e. Feed a client who had a stroke 3 months ago, 31. 4. a. 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. For which of the following actions should the nurse intervene? Which of the following statements should the nurse identify as an indication that the client needs further instruction? The nurse who made the medication error should take which of the following actions first? 1. 2. A nurse instructs a female client about collecting a midstream urine sample. b. Massage any bony prominences to promote circulation The unit is short one staff member and will receive a nurse from the medical surgical unit. Only a plain enema or soap enema can be given by the UAP. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). 1. Battery c. Decreased sodium excretion What is the primary factor for the charge nurse to consider when delegating care? The client is reporting anxiety, discomfort, and a feeling of bloating. Wrapping the dentures in tissue while the client sleeps The first client who needs treatment is the one with multiple injuries from a motor vehicle accident. 4. What was the hint? Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. c. Changing a dressing, 78. 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.

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