c. Hold an object away from her body as she lifts it b. Which of the following actions should the nurse take? 4. A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Drag and Drop the items from one box to the other. Empty the drainage bag at least every 8 hrb.) 1. A nurse on a medical unit is teaching a group of assistive personnel about handling clients' bed linens safely. Feed a client that had a stroke 3 months ago. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? A client receives a wrong medication. This schedule may leave some clients too exhausted to visit with family. This stage is when testing occurs to identify boundaries of interpersonal behaviors A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. 4. Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. NUR 204 ATI Management of Care Ch. 1-9 Flashcards | Quizlet a. A nurse is caring for a client in the orientation phase of the nurse-client relationship. The crying toddler has missing front teeth, but there is no indication this was the result of the hurricane. d. What have you done in the past to cope with this issue? A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. d. Go to employee health services, b. Place in priority order. This client is at a high risk of infection. C. Review a low-sodium diet for a client who has hypertension. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. d. Motor impairment, 84. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. 2. c. Explore the client's feelings about dietary modifications Correct: The medical nurse can be assigned to this client. Drag and Drop the items from one box to the other. b. Massage any bony prominences to promote circulation A nurse is assessing a client who is experiencing prostatic hypertrophy. Left upper forearm Respite care allows the primary caregiver time away from day-to-day care responsibilities, 75. c. Offer the client personal thoughts and beliefs b. 2. Refuse the assignment, being prepared for disciplinary action. 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. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. 3. c. Open the right flap with the left hand The expected standard of care was strict bed rest), 96. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." Asking for an explanation Encourage the client to use self-exploration 4. 1. c. We administer all medications intravenously to clients in this unit It happened so long ago - just get over it!" Client scheduled for a dressing change to foot ulcer. 6. A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Some general guidelines are necessary, with input from clients and family to individualize any special requests with assistance from the facility. d. Complete an incident report, 70. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 1. b. A nurse is preparing to obtain a blood specimen from a client by venipuncture. b. Which clients could be assigned to an LPN? 2. Incorrect: Just because the UAP is able to accomplish all daily assignments efficiently does not mean more work could be handled as effectively. Checking capillary refill beneath the client's fingernail a. Include any relevant statements the client made about the ulcer, 64. Involve the client in their plan of care. 4. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) 1. All these clients have a GI problem. 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. A high concentration of carbon monoxide can cause death b. I will come back later and we can talk A charge nurse is making client care assignments. a. I wish I didn't have to attach the electrodes to my skin The key word in the stem is first. Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. Review a low-sodium diet for a client with hypertension. 2. Where on the body is each type of skin found? Therefore, this client would not be a priority over a client who may be experiencing a MI. 2. 3. Client who requires teaching about the use of a patient-controlled analgesia (PCA) pump. 3. A nurse is discussing the norming stage of the group development process with a student nurse. A nurse is assessing a client who has narcolepsy. c. Review the client's progress toward personal objectives They are more direct when discussing issues b. Emptying a urinary drainage bag for a client who has pneumonia 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. c. I will cover the catheter so he cannot see it a. Prior to turning feeding back on, tube placement needs to be verified. Pain One nurse lifting as the client pushes with his feet This client needs careful monitoring and specialized care. Offer to take one of the clients. This is the most stable of the four clients which places this client last to be seen. d. Voided 30 mL frequently In what order should the emergency department triage nurse send these clients to a room for treatment? d. Talk with the client's partner, b. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. b. 8 Steps for Making Effective Nurse-Patient Assignments d. I will place a bath seat in my shower to use when I bathe, b. b. I will bear the weight of my body on my hands A client requesting assistance packing his belongings for discharge later today., This action is a defensive intervention, and does not address the quarrelsome behavior. Correct. Reach around the pack and open the top flap away from the body A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following info should the nurse include? This client can wait until the others are treated. For Option #3, you may have recognized MgSO4 as being magnesium sulfate. A client receiving heparin injections for deep vein thrombosis. A nurse is teaching a client who has a history of falls about home safety. 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? They are likely to wait for others to initiate conversation The nurse suggest that the family might need to respite care services. The RN requests reassigning at least one of the clients to another nurse. The nurse should base her pain management interventions primarily on which of the following methods of determining intensity of the client's pain? A nurse is caring for a client in a long-term facility who is receiving enteral feedings via an NG tube. Solved A charge nurse is making client care assignments. | Chegg.com Which of the following should the nurse include as a criterion for applying restraints? Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? 3. The unit is short one staff member and will receive a nurse from the medical surgical unit. Removing the abdominal dressing Which of the following actions is an example of a violation of confidentiality? Determine caregiver's stress level and coping strategies. 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. This action will promote the client's self-esteem, and may reduce the quarrelsome behavior. Make referrals to community services. In order to reorganize staffing, the nurse manager should initiate which action first? The client should be assessed first to rule out respiratory difficulty and hemorrhage. Which of the following physiological responses to prolonged immobility should the nurse expect? c. When asking the client how he completes his ADLs Which of the following tasks should the charge nurse reassign to a licensed nurse? (b) H3O+(aq)+OH(aq)2H2O(l);K=1.01014\mathrm{H}_3 \mathrm{O}^{+}(a q)+\mathrm{OH}^{-}(a q) \longrightarrow 2 \mathrm{H}_2 \mathrm{O}(l) ; K=1.0 \times 10^{14}H3O+(aq)+OH(aq)2H2O(l);K=1.01014 Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? Perform range of motion (ROM) exercises at least 2-3 times daily Which actions should be instituted by each unit's charge nurse? The fourth client the nurse should assess is the client diagnosed with Crohn's disease who had three semi-formed stools over the past shift. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. Nurses Report Sheet Template Nicu. This could cause a medical emergency. 2. Autonomy vs shame and doubt 4. a. a. 4. 5. a. I'll sit with my knees lower than my hips The provider must renew a restraint prescription every 8 hr. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Which task should the nurse take responsibility for completing? Provide an adaptive feeding device for the client A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following tasks should the nurse delegate to assistive personnel (AP)? Select all that apply. c. Complete an incident report 1. This client will also need a lot of education regarding anti-rejection medications. 1. b. a. I will begin 48 hr before the client's discharge a. Assign a nursing assistant to help the client with self-care activities. 4., & 5. Show client who has conjunctivitis how to clean the eyes. Remember, pick the killer answer first! b. Donation costs are the responsibility of the donor's family and estate The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. Describe the types of machining operations that can be performed on a lathe. d. Arrange the food groups clockwise on the client's place, b. I'll use the cleansing wipes from the front to back, 51. 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? Transfer essential medical record to the receiving facility. Feedback Alcoholic Anonymous Which of the following types of torts has the nurse committed? What options would be appropriate for the nurse to take? 5. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. The nurse caring for the client at the time of death requests organ donation d. Counting radial pulse Observe the client before taking further actions The nurse manager on a medical-surgical unit receives official notification that staff overtime must be decreased as a cost-saving measure. 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. 6. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. c. The nurse may serve as a witness to informed consent for organ donation Receive report from the emergency department (ED) on a new client. 1. b. c. Raised toilet seats d. Move to the opposite side of the pack and open the fourth flap, 54. Provides day to day direction and supervision to assigneddirect patient care staff . 1. I'm drinking plenty of fluids." Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. This is on the "Do Not Use" list of abbreviations because the period after the "Q" can be mistaken for "I", which would be interpreted as qid (four times a day) instead of the intended once daily dosage. It's just not the right time for me to do this b. 3. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? b. A nurse is preparing to move a client who is only partially able to assist up in a bed. b. b. Incorrect: The scope of practice for the UAP encompasses basic personal care needs, ambulating, and taking vitals; however, the nurse must still verify that all tasks are accomplished in a safe manner. (c) Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108\mathrm{Ba}^{2+}(a q)+\mathrm{CO}_3^{2-}(a q) \longrightarrow \mathrm{BaCO}_3(s) ; K=3.8 \times 10^8Ba2+(aq)+CO32(aq)BaCO3(s);K=3.8108 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. They disclose more personal information, a. Denial 4. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? 4. 1. d. Lean back in the chair, b. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. Injuries from a motor-vehicle accident can be life threatening. 2. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. c. Decreased sodium excretion A goal for this client is to use proper body mechanics at all times. 2. 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. 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. The report should contain consequences. (Select all that apply.). Which instruction provided by the nurse reflects effective communication regarding delegation to assistive personnel? 2. Incorrect: This option would create total chaos, interrupting sleep patterns and staffing schedules. 3. a. Discussing a client's surgical procedure with the nurse manager Richied5864 Richied5864 . Nursing questions and answers. Which of the following actions should the nurse take to assist the client with feeding? The nurse has received the change-of-shift report. The partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. 1. Select all that apply. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. 2. The client then states, "I have changed my mind and do not want to have the procedure done." b. Wash the tablet off with alcohol and place it in a clean medicine cup 5. Serve milk products separately from meals The nurse does not know the skills of the new UAP. a. 3. b. I will keep the fluorescent ceiling light on in my room at night The client asks about his medications and their effects. c. Measurement of residual urine after urination For which of the following tasks should the nurse wear protective eye equipment. 3. Have a pen and paper handy Which prescription should the nurse question and have corrected? This includes medication enemas. One important aspect is encouraging the flow of ideas between management and staff members. 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 nurse has just finished a wound irrigation for a client who requires contact precautions. Correct: Advance directives do consist of two types of legal documents: Power of Attorney and a Living Will. The client would develop severe cramping. b. 5. Since this is a postoperative client, It is important that the vital sign measurement is accurate to detect any changes or possible complications. Select all that apply. Select all that apply A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. A nurse instructs a female client about collecting a midstream urine sample. To focus on effective learning with this client, which of the following interventions should the nurse use? Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. c. Foot In option #4, we see that the leading zero is missing from the prescription. d. I decline this opportunity at this time, b. Places the soiled linen in the floor before bagging it 2. b. 1., 4., & 5. What is the best response by the charge nurse? d. Do you think crying will help? Incorrect: This client does not have a predictable outcome. a. It is within the LPNs scope of practice to administer antibiotics. A nurse in a long-term care facility is observing an AP changing the linen for a client who has fecal incontinence. Allowing staff to vent is acceptable but the nurse manager should focus on constructive methods of adjustment to the impending mandated changes. To which of the following rooms should the nurse assign the client? Incorrect: What seems to be going on with this client? The client's self-report of pain severity, 88. d. Reduced blood viscosity, a. Auscultating heart sounds 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. This client is not the nurse's first priority. 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). What interventions can the nurse delegate to the LPN/VN? (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. b. Nothing life threatening, but an assessment needs to be made regarding the ulcer. 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 instructions should the nurse include? Correct: The nurse has not been able to determine the skill of vital sign assessment for this new UAP. 2. b. 1. Select all that apply 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. Which nurse should be assigned to care for this client? a. A cardiac step down unit has requested float staff because of multiple impending admissions. The charge nurse is determining morning care assignments for several elderly clients awaiting discharge to an assisted living facility, including a client on bed rest with a skin tear and hematoma from a fall 5 days ago. The spouse can rescind the Advance Directive if the client becomes unresponsive. The assignment process requires constant evaluation and reevaluation of information and priorities. Incorrect: The nurse cannot assign teaching to the UAP. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. c. I'll clean the inside of the container with a wipe Although this will require assessment, this client is not the priority at this time. _________________ (magnanimous), a. generous (Select all that apply.) Client one day post kidney transplant. c. Leave a nightlight on in the client's room The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. b. A two-hour limit on visits discourages quality time. Once the client is stable, the UAP could perform this task. Currently, your census is 11, with one empty bed. Which of the following instructions should the nurse include? Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. 2. Announce the new changes at the monthly staff meeting. It's unfortunate that I have to be in the hospital for this treatment It is an inherited form of anemia, a condition in which there aren't enough healthy red blood cells to carry adequate oxygen throughout the body. However, this client would not need to be seen prior to the client with potential neurovascular compromise from a cast that is too tight. An adult (18 years or older) can create an advanced directive. Refuse the overtime assignment, being prepared for disciplinary action. In the following sentences, circle each incorrectly used lowercase letter. 3. b. 4. This could indicate a worsening of this client's condition. The charge nurse (an RN) must determine how best to assign another RN and one licensed practical nurse/licensed vocational nurse (LPN/LVN) to provide care to a group of clients on the day shift. The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. 3. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. Broth 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." A home health nurse is conducting a home safety assessment for an older adult client. Delegate 2 nurses to work with the client. 1. ATI Leadership and Management Questions - Leadership Management of Care a. Notify the charge nurse of the observations. 2. d. Determine if the client uses hearing aids, b. Focus on the client's present circumstances instead of his personal stories _____The house that we lived in for nine years has been sold. Drag and Drop the items from one box to the other. Well, many diabetics experience diabetic neuropathy and it is not a situation that makes this client unstable or critical. Which of the following infection-control precautions should the nurse use caring for this client? d. principal. he charge nurse is making client care assignments for the evening shift 2. 4. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 2. A client with diabetes admitted for debridement of a foot ulcer. 1, 3 & 5. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. 2. A client post pacemaker insertion, awaiting discharge instructions. Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. Removing the client's dentures 1. is a new graduate in orientation. Provide an adaptive feeding device for the client, 50. 1. When asking the client about his receptiveness to the transfer C-section planning discharge, postpartum infection, mastectomy. 1. Licenced practical nurses are a little less educated than registered nurses. Irrigate a client's ear canal. Which of the following items should the nurse include on the lunch tray? d. Remove and reinsert the NG tube, a. 3. c. Providing anticipatory guidance to a client in crisis Correct: The clue that should be picked up on here is that the client is now reporting that the cast has become too tight. Incorrect: This would unnecessarily alarm the clients. b. Incorrect: The charge nurse should first obtained the needed information and then decide whether to notify the nursing supervisor. Incorrect: The RN is responsible for assessment and evaluation of clients. The nurse is planning care for a client admitted with Alzheimer's Disease. Which of the following RNs should not be assigned to this baby? Pointing to the two glasses partially filled with water, the magician asked, "Which glass contains the least water?". A nurse is caring for a client who is immobile. 55. 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). Each state BON differs in that also some have treatment programs they administer themselves. 4. A nurse is adhering to standard precautions while caring for a group of clients. A nurse in a long-term care facility is caring for an older client who has dementia and begins to have frequent episodes of urinary incontinence. Oral surgeon Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. When the licensed person cannot determine this, the task should not be delegated. Incorrect: Delegating 2 nurses to work with the client does not address the client's behavior. 1-month-old infant with bronchiolitis with a respiratory rate of 60 6-month-old infant with pneumonia on oxygen 4-year-old child with nephrotic syndrome with 4 protein in the urine 6-year-old child 2-day post-op appendectomy with a surgical drain 3. The client is getting better. 8. When determining if the client is eating a well-balanced diet