A nurse is caring for a client within the intimate zone of the client's personal space. This is likely cholelithiasis, which will need to be checked out. Which of the following findings should the nurse expect? Select all that apply. This client would not be a priority to be seen before assessing the client with the cast that is too tight who may be developing compartment syndrome. 3. 3. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. 4. Which of the following statements should the nurse identify as an indication that the client needs further instruction? The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. Change the subject when the client behaves defiantly 3. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. Give magnesium citrate 296 mL at 3 PM today. A nurse enters an older adult client's room to insert a saline lock. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. 2. 3. Gown A nurse caring for a client is using active listening skills. The abdominal pain is worsening. a. I will be able to tell how much oxygen I'm getting by looking at the flowmeter 2. 1. Which of the following responses should the nurse provide? Narrative interaction Incorrect: Medications are not transferred with the client to a new facility. For which of the following tasks should the nurse wear protective eye equipment. Wears a gown when entering the room of a client who requires contact precautions So, now you must decide which of these high priority clients should be seen in what order. Which prescription should the nurse question and have corrected? A 10 year old school-age child would also be more cooperative, making it easier for the LPN to interact with that client. What task would be best to assign to the LPN/LVN? 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 client receives home health care and spends most of his day in a reclining chair. b. I will come back later and we can talk 2. 1. Select all that apply 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. Elderly client admitted 30 minutes ago with reports of constipation for four days. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. 1. Take several shallow breaths during the procedure A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? 1. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. Elevating the head of the bed 30- 40 for the client post thoracotomy 3. Which task would be appropriate for the nurse to assign to an LPN/VN? Select all that apply Explain to the RN that all the nurses have the same number of clients. 4. c. Hand-off technique When staff do not feel vested in any new process, there is a sense of underappreciation. d. Bend at the knees when picking up an object, 99. _________________ (magnanimous), a. generous Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. The nurse should perform which of the following activities in this space? 1. 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. Administering 3 g/hr IV of morphine would be extremely dangerous. d. Determine if the client uses hearing aids, b. A two-hour limit on visits discourages quality time. a. 4. The third client would be the one needing a dressing change. Electric cords behind the furnitrure Which of the following explanations should the nurse provide? c. Environment 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. Start MgSO4 at 3g/hr IV Incorrect: There are situations in which the LPN must notify the primary healthcare provider. b. I will call the doctor and get the prescription 2. Teaching about a medication Only a plain enema or soap enema can be given by the UAP. c. Washes and rinses her hands for 10 seconds, 11. c. Holds the soiled linen against her body while carrying it to the linen bag 208 d. Ambulating the client in the hallway, c. Explore the client's feelings about dietary modifications (this teaching intervention allows the client to express his acceptance of this change and focuses on affective learning), 80. This is an appropriate and safe action for the unlicensed nursing assistant to do. The last client would be the one needing dietary education. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. 4. c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. A nurse is caring for a client whose partner asks to speak with the nurse. a. 1. & 4. b. A client with epilepsy reporting an odd smell in the room. 2. Remove all metal necklaces Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. d. What have you done in the past to cope with this issue? What is the primary factor for the charge nurse to consider when delegating care? a. Select all that apply 3. Read all the current literature related to oral care on unresponsive clients. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. The command center is the only reliable source of information and will make any decisions needed by hospital personnel. Phone report to the receiving nurse. A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. d. Remove tea and coffee from meal trays, b. A nurse asks a client how he is feeling. Now, in Option #2, we see a dangerous prescription. d. What have you done in the past to cope with this issue? Which of the following statements should the nurse identify as an indication that the client understands the instructions? Witness the client's signature (verify that the client is consenting to voluntarily and appears to be competent to do so), 71. c. Use an aggressive tone of voice However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. The nurse should not lecture, scold or argue with the float nurse. Incorrect: The charge nurse does not have to assess every client. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. 4. Removing the client's dentures 1. A nurse is caring for a client who is scheduled for an elective surgical procedure. 10. A client receiving heparin injections for deep vein thrombosis. Which referral would most likely be appropriate for the nurse to make? I'm drinking plenty of fluids." If you give the magnesium citrate, which is a laxative, what will happen? d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. 3. 4. 1., 2., 3., & 4. 5. The nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" The first vital sign check was performed by the nurse. c. I will make sure my visitors smoke outside We do not know the extent of her injuries based on what the option tells us. Currently, your census is 11, with one empty bed. 4. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Provide an adaptive feeding device for the client The nurse would then start the 24 hour urine once the 1st void has been discarded. Identify and assess each incoming client. e. Dysuria, 49. 1. 3. Did you recognize ureterolithiasis as "kidney stones"? Based on the information provided in report, which client condition should be the nurse's priority? Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. The nurse suggest that the family might need to respite care services. Battery a. The LPN should refuse the intervention. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. c. Inform the surgical team to cancel the client's surgery In what order should the nurse see the clients? Incorrect: This again is assessment which is the role of the RN only. c. Offering false reassurance Allow the UAP to work without supervision. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. a. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. Which of the following actions should the nurse take first? d. Complete an incident report, 70. b. b. Protective An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. 3. 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. Which of the following statements should the nurse identify as an indication the client needs further teaching? 4. Which of the following responses should the nurse make? Select all that apply 2. Client to receive dietary education. 1. Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? c. Hold an object away from her body as she lifts it 2. 3. They are more direct when discussing issues Showing disapproval A nurse is preparing a sterile field. (Select all that apply.). C-section planning discharge, postpartum infection, mastectomy. 208 (a client who has TB requires airborne precautions; that means a private room with negative air pressure flow), 21. a. Perform range of motion (ROM) exercises at least 2-3 times daily Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. This stage is when testing occurs to identify boundaries of interpersonal behaviors Which client should be assigned to the most experienced nurse? Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Complete blockage of the large intestine. (Select all that apply.). A nurse is caring for a client in the orientation phase of the nurse-client relationship. Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Of my three brothers and sisters, my sister Giselle has the best sense of humor. d. Expect minor discomfort after the procedure, b. I will come back later and we can talk (offers herself to client which encourages open communication). The charge nurse's best response is to first obtain the needed information to make the best decision. A nurse is planning to discharge a client who has quadriplegia to his home. What options would be appropriate for the nurse to take? This nurse does not have much experience on this unit and may not have cared for a client with postpartum preeclampsia before. A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. A goal for this client is to use proper body mechanics at all times. 3. 3. Wrapping the dentures in tissue while the client sleeps Which of the following items should the nurse include on the lunch tray? 3. 2. c. Changing a dressing Select all that apply. 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. The UAP can provide hygiene needs to a client such as perineal care and cleaning of the nares. a. 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. c. Leave a nightlight on in the client's room 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. d. Wait to discuss the behavior in the presence of others, a. 2. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. 1., 2., 3., & 4. 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. b. 1 A nurse who is on hormone replacement therapy. b. Incorrect: This client does not have a predictable outcome. d. When asking if the client took his medications this morning, 82. 3. Gather and apply dressings to open wounds. A nurse is performing care activities for a client in the zone of touch that requires his consent. a. Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. 4. 2. Four clients arrive for their appointment at a diabetic clinic. It also helps the client deal with issues that are important to him), 19. A client who is disoriented and awaiting transfer to a long-term care facility. 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. Administer sodium polystyrene sulfonate enema. A nurse is preparing medication for a client when another client has an emergency. The nurse should do this when repositioning is needed. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. It would not be appropriate to overload this new employee with extra work. 1. d. Have the client practice blood-glucose monitoring using a glucometer, d. When asking if the client took his medications this morning, 81. c. Offer the client personal thoughts and beliefs (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. Correct: Traction should never be relieved without a primary healthcare provider's prescription. d. Voided 30 mL frequently Correct: Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. e. Suctioning a client's new tracheostomy tube, d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 94. 4. To which of the following rooms should the nurse assign the client? In what order should the nurse assess assigned clients following shift report? 2. c. Provide the client with a diet high in protein a. Reach around the pack and open the top flap away from the body d. Identifying the client by name when making a referral for home health services, 30. A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. c. I'll clean the inside of the container with a wipe Report of feeling pressure "The client is weak on the right side, so please assist the client with dressing . Administer tap water enemas until clear at 6 AM. Ambulating a client who is 2 days post vaginal hysterectomy Which group of clients should she assign to the medical surgical nurse? Call the client's provider Ask for any staff objections to rearranging work hours. A nurse is caring for a client who is postoperative following an appendectomy. c. Check to see if the suction equipment is working Which of the following actions should the nurse take? There will likely be both physical and emotional injury that needs attention, which places this client third. a. a. d. Left forearm, b. b. 2. This is a diabetic clinic. c. Foot Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. 1. IV of D5 NS at 75 mL/hour with a 20 gauge catheter. In which situation should the nurse consult the client's advanced directive? Which of the following actions should the nurse take? 4. What task would be best to assign to the LPN/LVN? The worst complication following a thoracentesis is a possible pneumothorax; therefore, the nurse should assess this client first. a. I will wear gloves when removing food from the freezer b. Irrigate the NG tube with 100 mL of sterile water 3. Lisinopril 20.0 mg PO daily 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. 5. It is not a routine task. d. Places clean linen that touched the floor in the soiled linen bag, d. Decreased calcium excretion (prolonged immobility leads to the breakdown of bone tissue; result is decreased calcium excretion), 26. 4. Correct. b. Donation costs are the responsibility of the donor's family and estate 2. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. A person can be designated to make medical decision in the event the client cannot. Which clients should be assigned to the CNA? This action is a defensive intervention, and does not address the quarrelsome behavior. b. Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. INCORRECT: Clients with COPD are always short of breath and dyspnea is an expected finding during an exacerbation. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. 5. A nurse is teaching a client about the physical effects of chemotherapy. Adheres to the FMCNA Compliance Program, including followingall regulatory and FMS policy requirements. b. 3. Monitor for GI upset 30 minutes after meals. a. A nurse is providing care to a client who is on strict bed rest following surgery. D. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a a. This determination is needed to assure client safety is being considered. c. Tie linen bags securely at the top b. Assess the client 4. What interventions can the nurse delegate to the LPN/VN? b. This is the most stable of the four clients which places this client last to be seen. So what is wrong with option #1? b. a. 2. a. Hypotension Notify the board of nursing (BON) that the float nurse is an alcoholic. 2. with this question, the nurse is using which of the following communication techniques? a. 2. Which of the following actions is the priority for the nurse to include in the client's plan of care? Select all that apply. 2. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Furosemide 40 mg PO q.d. This individual should be provided appropriate comments of appreciation for this accomplishment. 4., & 5. Check environment for potential safety hazards. Place the client in a lateral position 3. Plan all care to be completed in early morning to allow afternoon for visitation. 1. This would be an acceptable task to assign to the UAP. It's just not the right time for me to do this 2. Discuss the competency of the surgeon Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. 3. 4. a. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. A nurse is preparing to move a client who is only partially able to assist up in a bed. Incorrect: Here, you have a client who needs teaching about intravenous pain management using a patient-controlled analgesia (PCA) pump. 4. 3. Channel A charge nurse is making client care assignments. 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. Teach caregivers memory enhancement aids. c. The restraints should promote the client's safety and prevent injuries Yes! 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. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? An adolescent client post appendectomy reporting pain. c. Physical therapist American Sickle Cell Anemia Association Convenience for the nursing staff or the client's family The nurse has just completed a 12 hour shift. It's unfortunate that I have to be in the hospital for this treatment 4. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. A client receiving a blood transfusion that requires monitoring. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? A nurse receives a client care assignment from the charge nurse that he believes is unfair. An adult (18 years or older) can create an advanced directive. Which of the following physiological responses to prolonged immobility should the nurse expect? A nurse is orienting a new assistive personal (AP) to the unit. 2. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). }? benefactor of the world. b. 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. d. Place the tablet directly into a medication cup, 36. A charge nurse is making client care assignments. Which client should the nurse assess first? Pain 1. Documentation of what occurred, and the client's assessment is required in the nurse's notes. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. b. Irrigate the wound with an antiseptic prior to obtaining the specimen It is within the LPNs scope of practice to administer antibiotics. The nurse asks why the client needs to know this. b. I'll use the cleansing wipes from the front to back Have a pen and paper handy Obtain a bedside commode for the client's use Evaluate pain relief after narcotic administration. What is the most appropriate action by the charge nurse? A client post pacemaker insertion, awaiting discharge instructions. 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.
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