5. A nurse is having difficulty caring for a client due to variables affecting the communication process. In sickle cell anemia, the red blood cells become rigid and sticky and are shaped like sickles or crescent moons. a. I will keep my walker at the end of my bed c. Explore the client's feelings about dietary modifications Select all that apply. Focus on the client's present circumstances instead of his personal stories A client receives a wrong medication. Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". Which of the following tasks should the nurse delegate to assistive personncl ( AP) ? Incorrect: The nurse retains the responsibility for the delegated task. a. a. After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. A nurse is administering a cold therapy application to a client. This could cause a medical emergency. A nurse is admitting a client from a long-term care facility. d. Use attentive listening with the client, d. Water heater temp 54.4 C (130 F) (no higher than 49 or 120) Therefore, this would not be the most appropriate nurse to assign to this client. Correct: If suspicious behavior occurs, it is important to keep careful, objective records. When asking the client about his receptiveness to the transfer This client should report an improved respiratory, not shortness of breath. 3. 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. Occupational therapist The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. 3. b. 4. It happened so long ago - just get over it!" Complete a client assignment sheet for the oncoming staff. Incorrect: The RN is responsible for assessment and evaluation of clients. Aplastic Anemia Support Group. 2. 3. a. c. Measurement of residual urine after urination Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. Correct: An LPN should be assigned clients with predictable outcomes. d. Discard the prepared medications and begin again after returning, d. I will wear synthetic clothing and woolen socks when using my oxygen (woolen and synthetic materials can generate static electricity and oxygen is a flammable gas - the client should wear cotton), 73. 1. Which of the following actions should the nurse take? Include any relevant statements the client made about the ulcer d. Use soap and water to wash the catheter after each use, c. Consensus evolves in this stage (consensus occurs and cooperation develops during the norming stage), 34. When the licensed person cannot determine this, the task should not be delegated. a. TRAINED TO BE RELIEF CHARGE NURSE FOR THE UNIT, COMPLETE PATIENT ASSIGNMENTS, CUSTOMER SERVICE AND PROBLEM-SOLVING PROFICIENCY JUNE 2021 - JUNE 2022 STAFF RN - 3C GI MED SURG PROFICIENT IN . d. Respite care is a continuation of psychological support after a family member dies. Monitor for behavioral changes. 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. d. I have a set of my brothers' crutches in the basement I can also use, a. 1., 2., 4., & 5. 4. Which of the following client statements indicates an understanding of the procedure? a. 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. 1. Provide positive feedback to the UAP. The reason for the UAP not feeding the client needs to be determined. Correct: The hospital nurse to client staffing ratio should reflect the complexity of nursing care for high acuity clients. 1. The nurse should initiate a referral with which of the following members of the interprofessional health care team? Ask the float nurse, "Have you been drinking?" The supervisor can only send one LPN/LVN to the floor. 3. 2. Following a large hurricane, multiple clients arrive at the emergency room for treatment. What action should the nurse take after mistakenly administering the wrong medication? The nurse should perform which of the following activities in this space? This action is a defensive intervention, and does not address the quarrelsome behavior. 2. Select all that apply b. I should call my doctor if I find it harder to concentrate 3. Which preoperative prescription should the nurse question? 1. The nurse has received the change-of-shift report. 2. This client is stable and predictable. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. A client receiving heparin injections for deep vein thrombosis. The charge nurse knows what client would be most appropriate for this LPN? 1. 3. A post-cardiac catheterization needing assistance with bedpan. Initiate oxygen and IV lines as needed. Wrapping the dentures in tissue while the client sleeps b. Client prescribed antibiotics for cystitis. Which of the following findings indicates that the client is meeting this goal? A nurse is providing discharge teaching for a client who requires home oxygen therapy. a. Notify the primary healthcare provider of transfer completion. The charge nurse delegates a licensed practical nurse (LPN) to perform an intervention that is not within the scope of practice for the LPN. Two hours . A family member requests that the nurse apply restraints. e. Throw rugs, 40. 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. 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. Client scheduled for a dressing change to foot ulcer. a. Shakes the soiled linen to remove any toilet paper remnants c. Inflate the balloon when the urine flow stops d. I'll carry heavy objects close to my body, d. Places clean linen that touched the floor in the soiled linen bag, 25. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? Refuse the assignment, being prepared for disciplinary action. There may be a good reason that the tray was not served. Which region of the tRNA pairs with mRNA? 2. 2. c. Distended bladder 1. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Which client would be appropriate for the RN to assign to the LPN? Provide an adaptive feeding device for the client 4. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Client #3 is receiving heparin sub-q for deep-vein thrombosis, and sub-q injections are within the LPN's scope of practice. d. What have you done in the past to cope with this issue? Discussing a client's surgical procedure with the nurse manager Incorrect: This prescription is written correctly. 1. NURSING ASSIGNMENT- delegation in the workplace | Studymonk 1. 5. Call the client's provider Incorrect: Since this client has an obstruction, anything the client eats will not be able to come out. d. Voided 30 mL frequently c. Providing anticipatory guidance to a client in crisis Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. 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 new UAP is efficiently completing all daily assignments accurately and in a timely manner. 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. 5. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. 3. M4 Client Care Assignment.pdf - Making Client Care b. Determine which personnel could be sent to the command center. a. Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. Patient safety must remain the priority. a. The facility has insurance that will cover malpractice litigation Comatose client with end stage chronic obstructive pulmonary disease. A nurse is preparing to obtain a blood specimen from a client by venipuncture. This is a diabetic clinic. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. 10. What is the major histological difference between thick and thin skin? The nurse has just completed a 12 hour shift. A nurse is preparing to move a client who is only partially able to assist up in a bed. d. Clients are placed on artificial life support before organ and tissue donation can occur, a. I'll sit with my knees lower than my hips (client should sit with knees slightly higher than their hips to prevent injury), 24. Show client who has conjunctivitis how to clean the eyes. Use double bagging to remove soiled linen from the client's room 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. Which of the following statements should the nurse identify as an indication that the client needs further teaching? Notify the primary healthcare provider. Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? 3. The nurse prefers to check all vital signs on all clients. The cleint's family asks the nurse for info about this type of care. The nurse should not lecture, scold or argue with the float nurse. Symbolic communication 3. a. I will keep spare crutch tips handy a. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. This task cannot be delegated to the LPN/LVN. 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. b. Make referrals to community services. Total abdominal hysterectomy, bladder suspension with A&P repair, client with breast reduction. c. Changing a dressing, 78. d. Explain the procedure to the client if they do not understand, c. Lock the medication in a room and finish preparing it after returning from the emergency (securing them and returning later to finishing preparing and administering them decreases the risk of medication errors), 72. This service began with the client's admission to the hospital, 18. Therefore, the nurse with the labor and delivery experience would be more appropriate to assign to this client. Serve milk products separately from meals 2. c. I will inspect my crutches everyday for signs of wear Protective a. Risperidone .5 mg PO daily a. Hypotension A nurse is caring for a client who has a mental health disorder. Select all that apply The nurse is using which level of communication at this time? Which of the following actions should the nurse take? 4. 1. A nurse is working with an assistive personnel (AP) to Which of the following findings should the nurse expect? This client can wait until the others are treated. 4. A charge nurse is making client care assignments. d. Do you think crying will help? This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. 4. a. Which clients should be assigned to the CNA? I'm drinking plenty of fluids." Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. b. Only a plain enema or soap enema can be given by the UAP. 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 last client would be the one needing dietary education. Determine caregiver's stress level and coping strategies. 2. 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). Select all that apply Which of the following actions should the nurse include in the plan? The charge nurse must triage and assign clients to appropriate staff. 3. c. When asking the client how he completes his ADLs c. Initiate a liquid diet for the client The expected standard of care was strict bed rest), 96. c. Document in the client's medical record that she completed an incident report Checking capillary refill beneath the client's fingernail Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. The nurse cannot assign assessment and evaluation of the nursing process to the UAP. This situation is considered an external disaster which means the hospital will be expecting multiple victims. Everyone knows there are others who can chair this committee better than me 4. 4. 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. b. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. Select all that apply. Besides, a charge nurse is a leader on the floor and should possess . b. c. Interpersonal (interpersonal communication is face-to-face interaction with another person. For which of the following actions should the nurse intervene? a. "The client is weak on the right side, so please assist the client with dressing . Administer tap water enemas until clear at 6 AM. Which of the following actions is the nurse's priority? e. an open perineal wound, 92. The nurse voices his concern to the charge nurse. A nurse is caring for a client who is postoperative following an appendectomy. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. 4. 1. The client must understand the need for restraints Photo comes from the Greek word for light. Document what the nurse believes was the cause of the ulcer development Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. 1. 4. This client could be transferred with traction still maintained. Relax her abdominal muscles when she lifts an object c. Lock the medication in a room and finish preparing it after returning from the emergency 2. The nurse considers various ideas submitted by team members. The area surrounding the insertion site feels warm to the touch, 61. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. c. The nurse may serve as a witness to informed consent for organ donation c. Tie linen bags securely at the top Assist the float nurse with the clients case. Which of the following responses should the nurse make? Administering IV pain medication to a two day post op client. Correct: The nurse should recognize that this child has a very low absolute neutrophil count (ANC), which is referred to a neutropenia. 1., 4., & 5. c. Hand-off technique (Select all that apply.) c. Raised toilet seats A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. b. I'll do exercises that strengthen my abdominal muscles b. I'll use the cleansing wipes from the front to back Ambulating a client who is 2 days post vaginal hysterectomy The nurse chooses to confront the client. -Review a low-sodium diet for a client who has HTN Obtain a client's consent This is the most stable of the four clients which places this client last to be seen. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. d. Explain oral hygiene to a client receiving chemo It can result in muscle spasm and tissue damage. Make nursing assignments appropriate to the skill level . Besides yourself, there are the following staff: Your unit has 12 beds. Review the action of insulin therapy A nurse wants to find out a better way to perform oral care on unresponsive clients.

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