Incorrect: This would unnecessarily alarm the clients. a. (d) AgCl(s)Ag+(aq)+Cl(aq);K=1.81010\operatorname{AgCl}(s) \longrightarrow \mathrm{Ag}^{+}(a q)+\mathrm{Cl}^{-}(a q) ; K=1.8 \times 10^{-10}AgCl(s)Ag+(aq)+Cl(aq);K=1.81010. Electric cords behind the furnitrure Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? d. Social conversation, a. 3. a. Which of the following types of intervention is the nurse using to promote the development of the nurse-client relationship? a. the nurse responds: "It must be very frustrating to encounter this kind of attitude." The nurse is working with a new unlicensed assistive personnel (UAP) on a post-operative unit. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. 2. a. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? d. I will begin once the client's insurance company approves discharge coverage, b. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). The command center is the only reliable source of information and will make any decisions needed by hospital personnel. c. I should purchase a carbon monoxide detector for my home Placing the traction weights on the bed to transfer the client to x-ray. Provides day to day direction and supervision to assigned direct patient care staff. c. Shivering 3. Select all that apply. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. 5. c. Hallucinations at the onset of sleep 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. 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. 5. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. Which of the following responses should the nurse make? 3. They are more direct when discussing issues What is the best response by the charge nurse? d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Which of the following actions should the nurse take regarding informed consent? 2. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. 2. This is not a situation that requires the LPN to notify the primary healthcare provider. The RN with 8 years' experience in the Intensive Care Unit. c. Palpating for pedal edema Communicates with the physician and other members of the healthcare team to interpret, adjust, and complete patient care plans. The client's self-report of pain severity, 88. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. 3. PURPOSE AND SCOPE: Supports FMCNA's mission,vision, core values and customer service philosophy. 1., 3, & 4. a. b. Negligence There may be a good reason that the tray was not served. c. Can you tell me why you chose me? Correct: The nurse's level of fatigue must be considered especially under conditions of mandatory overtime. The second client that should be given a treatment room is the elderly client who fell and fractured the left femoral neck. The charge nurse must assign the clients to a team consisting of RNs, LPN/LVNs, and one CNA. 3. 6. 2. 1. This client is at a high risk of infection. d. There is no blood return when the tubing is aspirated, c. I will cover the catheter so he cannot see it (using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter), 62. (Select all that apply.). Incorrect: The client who was diagnosed with rheumatoid arthritis will need discharge teaching and may be wanting to go home quickly, but this client would not take precedence over the client with the cast that has become too tight. A nurse receives a client care assignment from the charge nurse that he believes is unfair. 3. 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. c. Notifying the provider of physical exam findings c. Hold an object away from her body as she lifts it 4. Rewrite each incorrect sentence to correct the error. 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. c. Decreased sodium excretion Now, in Option #2, we see a dangerous prescription. Discarding the first urine voided by the client starting a 24 hour urine test. c. I will place an area rug at the entry of my bathroom Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. b. Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. Which of the following info should the nurse include? Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. What task would be best to assign to the LPN/LVN? Elderly client admitted 30 minutes ago with reports of constipation for four days. The client is apparently stable and does not require any advanced assessment skills or specialized care. a. I will keep my walker at the end of my bed A nurse is caring for a client who is immobile. A nurse is preparing medication for a client when another client has an emergency. 2. 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. 2. The nurse voices his concern to the charge nurse. The abdominal pain is worsening. 3. b. 1. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6 on a scale of 0 to 10. d. Slap the client on the back several times, a. Bathe a client who had an amputation 2 days ago The key word in the stem is first. a. The expected standard of care was strict bed rest), 96. 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. A nurse is discussing the norming stage of the group development process with a student nurse. Schedule visiting times in two-hour increments so clients are not overwhelmed. Document what the nurse believes was the cause of the ulcer development 3. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. Client reporting epigastric pain and nausea after eating. Place the pack on a sterile work surface A client receives a wrong medication. Select all that apply d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. Phone report to the receiving nurse. Narrative interaction (involves asking a client to share personal stories so the nurse can better understand the context of a client's life in the working phase of a nurse-client relationship), 47. Which task would be appropriate for the nurse to assign to an LPN/VN? Incorrect: Discharging a client includes teaching and a review of medications to be taken at home. 4. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Incorrect: This client does not have a predictable outcome. & 5. Client who received blunt abdominal trauma in a motor vehicle accident who is reporting a worsening of the abdominal pain. The nurse can also accept the assignment; however, that nurse should document professional concern for client safety and the process you used to inform the facility (manager) of your concerns. Client with a T-5 spinal cord injury beginning rehabilitation therapy. Use the tablet's packaging to pick it up from the counter 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. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. 1. Take vital signs every two hours for the patient with the cholecystectomy in Room 6022. 3. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen A client with epilepsy reporting an odd smell in the room. 2. Which clients should be assigned to the CNA? A nurse is discharging a client who has come to the outpatient clinic with an ankle sprain. Report of feeling pressure Incorrect: The nurse is responsible for evaluating a client. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? But the evidence-based care leaders are trained to help nurses through the proper process of evidence based research. 5. 2. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. A charge nurse is observing a group of newly licensed nurses. c. Foot Irrigate a client's ear canal. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 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. Select all that apply. Show client who has conjunctivitis how to clean the eyes. A nurse is preparing to obtain a blood specimen from a client by venipuncture. 2. a. Hold the penis at a 30 to 45 degree angle when inserting the catheter Based on these findings, to which of the following providers should the nurse request a referral for the client? Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). Turn on local news for up-to-date information on the train derailment. Which of the following actions should the nurse take prior to administering the tube feeding? 1. Nothing will get passed the complete blockage. 4. c. Review a low-sodium diet for the client who has hypertension Correct: Clients diagnoses with folic acid anemia typically have developed the anemia from chronic alcohol abuse. A nurse is performing care activities for a client in the zone of touch that requires his consent. 3. Elderly client who fell and fractured the left femoral neck. c. I'll wear low heeled shoes from now on a. Bathtub with rails 1. They have found my address and are coming for my family!" b. Which of the following actions should the nurse take? Which of the following statements should the nurse identify as an indication that the client understands the instructions? Hanging a new bag of total parenteral nutrition (TPN). (Select all that apply.) b. d. Remove and reinsert the NG tube, a. The report should contain consequences. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. d. Fill linen bags with as much soiled linen as possible, b. Negligence (negligence is the failure to provide the expected standard of care. d. Routine acquisition of a urine specimen I'm drinking plenty of fluids." The client should be assessed first to rule out respiratory difficulty and hemorrhage. b. b. d. Motor impairment, 84. 2. 4. This situation is considered an external disaster which means the hospital will be expecting multiple victims. 3. d. Identity vs role confusion, b. Assigning tasks to an AP (delegation is considered indirect care), 13. 3. Autonomy vs shame and doubt Determine the client's level of fluency in his primary language (it is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand). c. Lock the medication in a room and finish preparing it after returning from the emergency A client post pacemaker insertion, awaiting discharge instructions. _____The house that we lived in for nine years has been sold. b. I'm so sorry to hear about this b. A nurse is assessing a client at a follow-up clinic for acute low back pain. 2. Licenced practical nurses are a little less educated than registered nurses. The nurse who made the medication error should take which of the following actions first? What is the most appropriate action by the charge nurse? The client is considered unstable until assessed by the nurse. d. Voided 30 mL frequently, 48. d. I hope I don't have to take as many pain pills, d. Left forearm (allows for easy access and doesn't interfere with the IV catheter), 46. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. Incorrect: Gloves should be worn to remove dentures and a gauze used to grasp the dentures. The nurse considers various ideas submitted by team members. It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility nurse in order to support continuity of care. d. I have a set of my brothers' crutches in the basement I can also use, a. c. Nonfat milk Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? 1. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Place the client in a lateral position c. Raised toilet seats c. Document in the client's medical record that she completed an incident report A high concentration of carbon monoxide can cause death A float nurse arrives on the unit to assist in the care of clients for the shift. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? The nurse cannot assign assessment and evaluation of the nursing process to the UAP. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. The client asks the nurse, "Why do I need that? a. EXAMPLE: Of my three brothers and sisters, my sister Giselle has the better sense of humor. Relax her abdominal muscles when she lifts an object Try different methods of oral care on unresponsive clients to see what works best. c. Assist the client to the floor and begin mouth-to-mouth 4. The charge nurse knows what client would be most appropriate for this LPN? This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. Clients over the age of 65 must have a saline lock according to facility policy Select all that apply 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. 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. 4. This will take a lot of time, and the charge nurse can get the information needed from the nurses caring for the clients in order to make appropriate client assignments for the next shift. Feed a client that had a stroke 3 months ago. Incorrect: This client is post cardiac catheterization and remains on bedrest; therefore, the affected leg must be kept straight to prevent femoral hemorrhaging. 2. c. Do not eat or drink anything the morning of the test c. Interpersonal (interpersonal communication is face-to-face interaction with another person. a. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. 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). the nurse responds, "don't worry, no one will harm your family." So, this client who is receiving PRN pain medication is certainly someone that the LPN could be assigned to. 4. Even though this nurse just had a baby, there is no risk of her transmitting this virus to her child. Monitor client for pain while assisting with ambulation. This could indicate a worsening of this client's condition. e. The urge to move the legs when trying to sleep, 66. Give magnesium citrate 296 mL at 3 PM today. The nurse has another priority. Which of the following actions should the nurse include in the plan? d. Voided 30 mL frequently The nurse should perform which of the following activities in this space? c. I'll bear weight on my ankle for 10 minutes every hour 4. Twist at the waist when she moves an object to one side A nurse receives a client care assignment from the charge nurse that he believes is unfair. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? Which clients should be assigned to the CNA? 1. Provides day to day direction and supervision to assigneddirect patient care staff . 4. 1. Family cannot withdraw the Advance Directive and make decisions that go against the client's wishes made within the document. 2. 55. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Explain administration is demanding a decreased overtime. Simply accept the assignment since overtime is mandatory. Pick up the tray and tell the UAP that they didn't do a good job. Prior to shift report, the charge nurse is making assignments for the nurses on the shift. Incorrect: The charge nurse does not have to assess every client. Therefore, the nurse with Labor and Delivery experience would be the most appropriate one to assign to care for this client who has postpartum preeclampsia. Which of the following is the priority action by the nurse? c. Providing anticipatory guidance to a client in crisis Use adult diapers to prevent frequent clothing changes 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. b. I will call the doctor and get the prescription 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. 1., 2., 3., & 4. A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Select all that apply d. Water heater temp 54.4 C (130 F) Document current functional status assessment Functions as the hemodialysis team leader in the provisionof chronic hemodialysis care and treatment. Places the soiled linen in the floor before bagging it 4. C. Review a low-sodium diet for a client who has hypertension. c. The nurse may serve as a witness to informed consent for organ donation If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. Which of the following instructions should the nurse include? December 5, 2020. Incorrect: Hanging a new bag of TPN is parenteral therapy requiring a central line. b. Dons gloves to empty a urinary drainage device Incorrect: Medications are not transferred with the client to a new facility. These individuals are selected by the charge nurse, and do not have to be nurses. A nurse is teaching a client about carbon monoxide poisoning. 2. Which of the following client statements should indicate to the nurse the need for additional teaching? Select all that apply. The nurse is focusing on which of the following elements of the communication process? A nurse is discussing indications for urinary catheterization with a newly licensed nurse. b. 3. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. Measure urine output when client voids. 1. b. Emptying a urinary drainage bag for a client who has pneumonia Which of the following actions should the nurse take to assist the client with feeding? If the decimal point is missed in this situation, the client could receive 5 mg instead of the intended dose of 0.5 mg of risperidone. 2. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". d. Proceed with the preparation of the patient's surgical procedure, 15. Which client should be assigned to the most experienced nurse? The primary healthcare provider may have suggestions but this is not the best first action. (SATA) -Bathing a client who had an amputation 2 days ago. Correct: Disconnecting NG tube suction is an appropriate task for the UAP. Correct: Traction should never be relieved without a primary healthcare provider's prescription. The charge nurse's best response is to first obtain the needed information to make the best decision. d. Anger, b. Ask the client to perform a return demonstration of insulin injection 9. The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Well, do you see the q.d.? b. I will try to anticipate and avoid stressful situations when possible Select all that apply Obtain a urine specimen from a client with an indwelling Foley catheter. Based on the information provided in report, which client condition should be the nurse's priority? A nurse is implementing direct nursing care for a group of clients in an acute care facility. 2. Flexible hours allow clients and families to spend more quality time together, increasing positive outcomes and satisfaction. 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. The client receives home health care and spends most of his day in a reclining chair. b. Wash the tablet off with alcohol and place it in a clean medicine cup Write N next to the nonessential clauses and E next to the essential clauses. The option does not say the client is terminal, in a vegetative state, or in a coma. 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. 3. But the client does need to be assessed prior to the client with Crohn's disease who is improving. a. Wears a gown when entering the room of a client who requires contact precautions c. Hand-off technique Which of the following communication techniques should the nurse use during this phase? a. Incorrect: The hysterectomy client needs to be ambulated to avoid post op complications. 1. Incorrect. A nurse is caring for a client who states, "I have got to get out of this hospital! 5. Relief of urinary retention 2., 3. 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. Thus they are kept in charge of basic patient care like administration of tests, medicines and proper provision of the required treatment. Elderly clients have special fluid and electrolyte issues after a fall. This is an elderly client who is a new admit. Evaluate client's safety risk factors. Determine caregiver's stress level and coping strategies. 1. PURPOSE AND SCOPE: Functions as the hemodialysis team leader in the provision of chronic hemodialysis care and treatment. d. Two nurses using a friction-reducing device, d. Use attentive listening with the client (when establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding), 39. 3. Correct: The LPN has the right to refuse a delegated intervention that is not within the scope of practice for the LPN. Incorrect: This is appropriate because this position will improve gas exchange and breathing for a client after thoracic surgery. c. I'll clean the inside of the container with a wipe a. Hypotension The client with chronic emphysema has expected shortness of breath. This client could be transferred with traction still maintained. Which of the following should the nurse include as a criterion for applying restraints? What interventions can the nurse delegate to the LPN/VN? Personal liability coverage is not mandatory, but you should consider purchasing your own coverage, 87. Which of the following should the nurse identify as an interpersonal variable? butter, which contain 16 g of protein, 7 g of carbohydrates, 5. (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. Incorrect: Pernicious anemia is a decrease in red blood cells that occurs when the intestines cannot properly absorb vitamin B12. b. The nurse is using which level of communication at this time? a. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. 2. 3. The nurse should not be assigned to provide care if impairment is suspected. 2. 3. What was the hint? The RN with 2 weeks' experience on the postpartum unit. 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 of a step-down coronary care unit has 24 clients in varying degrees of cardiac rehabilitation. 3. 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 nurse asks the client, "Are you feeling anxious about the results of your colonoscopy?" 3. This could cause a medical emergency. c. Provide the client with a diet high in protein Which of the following actions should the nurse take? Incorrect: Although this action appears to be opening lines of communication, the nurse manager is actually fostering animosity in a situation where the outcome is already predetermined. 2. Monitor for GI upset 30 minutes after meals. 4. c. Explain the risks and benefits of the procedure This client is stable and predictable. Allow the UAP to work without supervision. Which actions should be instituted by each unit's charge nurse? Notify clients that the disaster plan has been put into effect. So, now you must decide which of these high priority clients should be seen in what order.
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