4. 2. 5. This should not be delegated to the LPN/LVN. a. 3. Each state BON differs in that also some have treatment programs they administer themselves. The LPN should refuse the intervention. the nurse responds: "It must be very frustrating to encounter this kind of attitude." Offer to take one of the clients. Obtain a urine specimen from a client with an indwelling Foley catheter. a. The nurse is responsible for the assessment of all vital signs of post-op clients. b. Grape juice Hearing loss c. Check to see if the suction equipment is working 6. A client with an above the knee amputation reporting phantom pain. 3. It would not be appropriate to overload this new employee with extra work. a. Auscultating heart sounds b. An adolescent client post appendectomy reporting pain. Drag and Drop the items from one box to the other. The nurse who made the medication error should take which of the following actions first? c. We administer all medications intravenously to clients in this unit Secondly, staff will be far too busy to watch television or listen to the radio with all the activity occurring hospital wide. We see that the temperature is already elevated, which makes us worry that infection is present. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. This stage involves constructive efforts on the part of the group members Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. Which clients should be assigned to the CNA? This stage is when testing occurs to identify boundaries of interpersonal behaviors 2. Incorrect: The RN is responsible for assessment and evaluation of clients. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). c. Palpating for pedal edema 1. Select all that apply. Encourage clients and families to develop mutually appropriate visitation times. The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. The RN requests reassigning at least one of the clients to another nurse. Incorrect: Moistening the dentures will ease insertion. 3. 3. Changing a colostomy bag. Write the letter of your choice on the answer line. b. a. Select all that apply These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. Incorrect: A client diagnosed with Guillain-Barre' is mentally competent and being on a ventilator does not indicate that the client has lost decision-making capacity. Correct: The client has the right to be involved in the decision making of their care. Which of the following infection-control precautions should the nurse use caring for this client? Client reporting epigastric pain and nausea after eating. 1. 6. c. Providing anticipatory guidance to a client in crisis What is the best care assignment for this client? 4. Focus on the client's present circumstances instead of his personal stories Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. Select all that apply Compartment syndrome could be developing which can impede circulation and cause nerve damage. Initiative vs guilt Review the action of insulin therapy . A nurse is caring for an older client who states, "I am afraid that I may fall while walking to the bathroom during the night." c. Gender Assigning blame for the changes to administration will not help staff adjust. Assign a nursing assistant to help the client with self-care activities. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? d. Explain oral hygiene to a client receiving chemo 3. Incorrect: This prescription is written correctly. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. b. Where on the body is each type of skin found? Which of the following responses should the nurse provide? A cardiac step down unit has requested float staff because of multiple impending admissions. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. d. Place the tablet directly into a medication cup, 36. b. d. Go to employee health services, b. This could indicate a worsening of this client's condition. Select all that apply b. Speak to the UAP to determine what happened with the feeding. A school-aged child with a fractured femur who is in balanced suspension traction. This client is at a high risk of infection. An experienced neurological nurse should be assigned to this client to assess and manage for signs and symptoms of increasing intracranial pressure. e. Dysuria, 49. Observe the client before taking further actions 3. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. A. Transporting a client who experienced a stroke 72 hr ago to the radiology department c. Open the right flap with the left hand When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. Which of the following responses should the nurse make? d. I will wear synthetic clothing and woolen socks when using my oxygen, c. Check to see if the suction equipment is working, 74. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. 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. a. I will begin 48 hr before the client's discharge A nurse has just finished a wound irrigation for a client who requires contact precautions. Incorrect: The wash cloth is placed in the sink to prevent the dentures from breaking if they are dropped. b. A nurse is discussing the norming stage of the group development process with a student nurse. d. Offering sympathy, d. Test the pH of gastric aspirate (nurse should verify position of tube, testing pH is acceptable method between x-ray confirmations), 85. a. They are likely to wait for others to initiate conversation "Please explain what you mean by the word 'nervous'.". I'm drinking plenty of fluids." d. Reflection, c. Leave a nightlight on in the client's room (night vision may be impaired in older clients; a nightlight may help client recognize their surroundings and decrease the likelihood of disorientation), 37. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. 4. Teaching can be reinforced by the LPN/LVN, but they cannot perform the initial teaching. Which prescription should the nurse question and have corrected? A nurse is caring for an older client who is at risk for skin breakdown. The charge nurse is planning the staff assignments for the clients on a neurological unit. 1. 1. Incorrect: Informing is the same thing as teaching. 1. Education A nurse is admitting a client who has a partial hearing loss. Pick up the tray and tell the UAP that they didn't do a good job. 1. Administer tap water enemas until clear at 6 AM. d. Remove and reinsert the NG tube, a. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. d. Wears a respirator mask when entering the room of a client who requires airborne precautions, c. Industry vs inferiority (a school age child (6-12) is in this stage of development), 12. Serve milk products separately from meals c. Take the client to the bathroom every 2 hr 2. 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. The third client would be the one needing a dressing change. The body needs vitamin B12 to make red blood cells. b. c. Blood-tinged urine Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. Incorrect: This would unnecessarily alarm the clients. 3. is a new graduate in orientation. a. b. 4. A two-hour limit on visits discourages quality time. The nurse is focusing on which of the following elements of the communication process? Provide an adaptive feeding device for the client, 50. The nurse has another priority. The nurse considers various ideas submitted by team members. a. I'll sit with my knees lower than my hips c. Why are you crying? A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Removing the abdominal dressing Which of the following actions should the nurse take? Remember, pick the killer answer first! 4. Asking for an explanation b. Verbalize understanding of how the client feels If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. Showing disapproval 4. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. Complete a client assignment sheet for the oncoming staff. These are appropriate tasks for an UAP to complete. To which of the following rooms should the nurse assign the client? The charge nurse is making client assignments for a neuro-medical floor. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. Which action by an unlicensed nursing assistant would require the nurse to intervene? d. Custard 3. 4. a. b. c. Malpractice Discuss the issue with the leader of the "best practices" committee. They are able to manage tasks related to basic care. c. I will make sure my visitors smoke outside Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. A nurse receives a client care assignment from the charge nurse that he believes is unfair. The client states, "I'm feeling a bit nervous today." Incorrect: A slightly decreased pedal pulse to the affected extremity is not unusual following cardiac catheterization. Which of the following communication techniques should the nurse use during this phase? "The client is weak on the right side, so please assist the client with dressing . As the evening progressed, the unit tasks became very demanding and the nurse had to delegate several actions to the UAP. 2. Ask the RN why the assignment is too heavy. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 1. Incorrect: The client does need to have food; however, there is another action that should be performed first. a. Measuring vital signs After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Talk to each nurse about concerns related to assigned clients. The cleint's family asks the nurse for info about this type of care. Checking capillary refill beneath the client's fingernail 4. The nurse is using which of the following therapeutic communication techniques? A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. c. The client's culture c. I should purchase a carbon monoxide detector for my home 55. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. In which harmonic number n is the string vibrating? c. Explore the client's feelings about dietary modifications 1. A newly hired nurse in a long term care facility has been asked to assist with revising old policies regarding family visitation schedules. A client receiving a blood transfusion that requires monitoring. This is not a situation that requires the LPN to notify the primary healthcare provider. Select all that apply The nurse did not trust the new UAP. Removing the client's dentures 1. Answer the following question to test your understanding of the preceding section: b. Select all that apply. Triage and assign color-coded tags to each client. Risperidone .5 mg PO daily Correct: It would be best to explore the reason the RN thinks the assignment is too heavy. 1. When staff do not feel vested in any new process, there is a sense of underappreciation. 4. Following the teaching, the nurse asks the client to describe one physical effect. Witness the client's signature a. a. Bathe a client who had an amputation 2 days ago Report the incident to the charge nurse a. Incorrect: The nurse is assuming that the client's quarrelsome behavior is normal for this client. 4. 2. c. Assist the client to the floor and begin mouth-to-mouth It is within the LPNs scope of practice to administer antibiotics. The RN with 5 years' experience in the Labor and Delivery unit. There are a total of 10 adult clients. 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. 1., 3, & 4. Therefore, this would not be the most appropriate nurse to assign to this client. 4. Gown A nurse is adhering to standard precautions while caring for a group of clients. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. 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. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Donning gloves and using a gauze pad to grasp and remove dentures Incorrect: Teaching is outside the scope of practice for the LPN/LVN. Speak to the UAP first and then decide if a between meal supplement is needed. Make nursing assignments appropriate to the skill level . The nurse would then start the 24 hour urine once the 1st void has been discarded. But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 1. c. Contact One nurse lifting as the client pushes with his feet The client is getting better. 2. a. Feedback Correct: Disconnecting NG tube suction is an appropriate task for the UAP. When the licensed person cannot determine this, the task should not be delegated. c. Notifying the provider of physical exam findings b. Massage any bony prominences to promote circulation They have found my address and are coming for my family!" The surgeon initially prescribes a clear liquid diet. Which of the following actions should the nurse take? The nurse is using which level of communication at this time? b. a.) 5. Document current functional status assessment This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. 2. A person can be designated to make medical decision in the event the client cannot. Correct: Communication is important in delegation, as is follow-up. A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. Occupational therapist This is an appropriate and safe action for the unlicensed nursing assistant to do. c. Offer the client personal thoughts and beliefs e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. Inform the client of the need to avoid irritants such as carbonated beverages. 1. 2. A nurse wants to find out a better way to perform oral care on unresponsive clients. a. Incorrect: No, the monitoring is too specific for the med-surg nurse. Which referral would most likely be appropriate for the nurse to make? 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.