A lack of rapid eye movement (REM) sleep Which of the following tasks should the nurse plan to delegate to assistive personnel (AP)? Incorrect: It is out of the UAP's scope of practice to administer medication. Which client can be assigned to the LPN? Each unit functions differently, but the charge nurse's role is to make the unit run smoothly. The nurse prefers to check all vital signs on all clients. The provider must renew a restraint prescription every 8 hr. The client is apparently stable and does not require any advanced assessment skills or specialized care. Room 208 is a private, negative pressure airflow room; room 212 is a semi private, positive airflow pressure room; 214 is a negative pressure room, a semi private room; and room 216 is a private positive-pressure airflow room. This situation needs advanced monitoring and care, so this nurse with very little postpartum experience would not be the most appropriate to assign to this client. 3. 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. A client receiving heparin injections for deep vein thrombosis. 2. 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. 4. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? 4. b. Summarization C-section planning discharge, postpartum infection, mastectomy. b. This is outside the scope of practice for the LPN/LVN. Which prescription should the nurse question and have corrected? b. A nurse is providing discharge teaching for a client who requires home oxygen therapy. a. Shakes the soiled linen to remove any toilet paper remnants Which client would be appropriate for the RN to assign to the LPN? Which clients would be appropriate assignments for the LPN/LVN? Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. Correct: First, you must recognize that this client has the signs and symptoms of postpartum preeclampsia. Which region of the tRNA pairs with mRNA? A client on a surgical unit frequently quarrels with the staff. b. Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. c. Complete an incident report b. A nurse is preparing medication for a client when another client has an emergency. a. Each state BON differs in that also some have treatment programs they administer themselves. Incorrect: The RN is responsible for collecting data. 3. Which clients should the nurse assign to the LPN/LVN based on skill level and scope of practice? Which of the following items should the nurse include on the lunch tray? c. The nurse may serve as a witness to informed consent for organ donation b. Which nursing intervention should the charge nurse implement? c. Open the right flap with the left hand Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. 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. 4. 1. b. If the volume of the bucket is 4.67L4.67 \mathrm{~L}4.67L, how many grams of gold are there likely to be in 2.381032.38 \times 10^32.38103 cubic feet of soil? 1. d. Mask, 83. Incorrect: When a unit is very busy, the nurse should rely on the UAP if the person is competent to perform the tasks. Following a large hurricane, multiple clients arrive at the emergency room for treatment. 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. 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. Something new could have occurred with the clients, making the assignments too heavy. d. Decreased calcium excretion, c. Provide the client with a diet high in protein (inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown), 27. What task would be best to assign to the LPN/LVN? The best practice committee works to improve clinical practice based on current research. c. Take the client to the bathroom every 2 hr What is the best response by the charge nurse? Administer tap water enemas until clear at 6 AM. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction? Estimate the number of Calories in two tablespoons of peanut b. 3. a. Read all the current literature related to oral care on unresponsive clients. 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. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. Which of the following clients should the charge nurse assign to a licensed practical nurse (LPN)? Inform the client of the need to avoid irritants such as carbonated beverages. A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Correct: A medical-surgical LPN would likely have seen and cared for diabetics on the floor, including checking fingerstick blood sugars and injecting insulin. You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Irrigate a client's ear canal. a. d. Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours, 95. Ask the RN why the assignment is too heavy. a. Monitor client for pain while assisting with ambulation. b. b. A nurse who is breastfeeding her 4 month old. This item: Nursing Brain Sheet Multiple Patient Notebook - Nurse and CNA Report Sheet - 3 Patients per Template $1999 BadgeGuru by Tribe RN - 52 Cheat Sheets on 26 Nurse Badge Cards - Designed by Nurses, for Nurses - Essential for Nurses and Nursing Students - Bonus Access to Our Digital Resource Library - Inverted $1997 ($0. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. It is quicker to administer medications intravenously in the hospital c. Do not eat or drink anything the morning of the test Which of the following findings should the nurse identify as a safety risk? Which of the following actions should the nurse take prior to administering the tube feeding? 5. 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. d. Wait to discuss the behavior in the presence of others, a. This client needs careful monitoring and specialized care. Incorrect: What seems to be going on with this client? Correct. If the client is unstable, the nurse would retain the role of measuring the vital signs. d. Question the charge nurses about the care deficits that might have contributed to the ulcer's development, b. Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. 3. a. 2. 4. Following the teaching, the nurse asks the client to describe one physical effect. 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. A nurse is implementing direct nursing care for a group of clients in an acute care facility. Confrontation should occur in the presence of a charge nurse or supervisor. Correct: Did you notice the hint? a. Respite care provides holistic support and care for a client who is terminally ill 4. 4. The nurse would then start the 24 hour urine once the 1st void has been discarded. The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Hearing loss Use adult diapers to prevent frequent clothing changes The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. b. Irrigate the wound with an antiseptic prior to obtaining the specimen In the following sentences, circle each incorrectly used lowercase letter. a. A client with COPD complaining of shortness of breath on exertion. This could indicate a worsening of this client's condition. Though it may benefit staff to have one particular goal, some clients cannot tolerate to have everything performed at one time, and instead need short rest periods during personal care. Everything will be okay Complete a client assignment sheet for the oncoming staff. 2. Rewrite each incorrect sentence to correct the error. c. Inflate the balloon when the urine flow stops d. Reduced blood viscosity, a. Auscultating heart sounds 1. b. Which of the following physiological responses to prolonged immobility should the nurse expect? b. I will begin once the client's discharge order is written c. Inform the surgical team to cancel the client's surgery Incorrect: Atrial fibrillation places the client at risk for blood clots. The nurse also needs to be aware of the color and amount of urine voided. Client two days post percutaneous endoscopic gastrostomy (PEG) placement. Which of the following actions should the nurse take? A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Announce the new changes at the monthly staff meeting. Which of the following actions is an example of a violation of confidentiality? There are a total of 10 adult clients. d. The nurse has already considered alternatives to restraints, a. The nurse on a large surgical unit needs to evaluate several clients returning from procedures. A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. a. Which task would be appropriate for the nurse to assign to an LPN/VN? 1. Handoff and Nursing Report Sheet. a. Bathtub with rails 3. 55. b. Teach caregivers memory enhancement aids. The situation should be explored before bringing the supervisor in on the situation. The cleint's family asks the nurse for info about this type of care. Elderly clients have special fluid and electrolyte issues after a fall. Tenderness over the symphysis pubis These irregularly shaped cells can get stuck in small blood vessels, which can slow or block blood flow and oxygen to parts of the body. 3. 4. 3. Additional data includes pulse 100/min, RR 24/min, BP 124/76 mm Hg, and temp 36.8C (98.2 F). There may be a good reason that the tray was not served. This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. So, the UAP can assist a client to brush and floss teeth. What options would be appropriate for the nurse to take? 1. a. Clarification For which of the following tasks should the nurse wear protective eye equipment. Encourage the client to use self-exploration 2. The area surrounding the insertion site feels warm to the touch Obtain a urine specimen from a client with an indwelling Foley catheter. Provide an adaptive feeding device for the client 1. Ambulating a client who is 2 days post vaginal hysterectomy These individuals are selected by the charge nurse, and do not have to be nurses. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. d. principal. Risperidone .5 mg PO daily 2., 3. Correct: Cytomegalovirus is a viral infection that can be devastating to a fetus, especially in the first trimester. Decreased or suppressed respiration are priority. The client faces the direction of movement when sliding an object across the floor (sliding an object across the floor rather than lifting it prevents strain on the lower back muscles and facing the direction prevents from twisting his back). c. There is fluid leaking around the insertion site Checking capillary refill beneath the client's fingernail d. The presence of a bed alarm could have prevented the client from falling, b. Assess the client (to check if there is any harm to the client), 69. Accept assignment, documenting personal concerns regarding work conditions. Elderly client who fell and fractured the left femoral neck. 1. (Select all that apply.) Gather and apply dressings to open wounds. a. Incorrect: Irrigating a client's ear canal is outside the UAP's scope of practice. A high concentration of carbon monoxide can cause death The best practice committee utilizes current research in their recommendations. 4. b. Wash the tablet off with alcohol and place it in a clean medicine cup Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Everyone knows there are others who can chair this committee better than me 3. 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. Aplastic anemia is a rare but serious condition. 1. Which of the following statements by the nurse would provide UAP with the best directions about an assignment? 2. This schedule may leave some clients too exhausted to visit with family. This client will also need a lot of education regarding anti-rejection medications. 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 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. The client post PEG placement is stable. 4. d. Remove tea and coffee from meal trays, b. e. Feed a client who had a stroke 3 months ago, 32. To confirm the placement of the NG tube d. They disclose more personal information, a. "Please explain what you mean by the word 'nervous'.". Include any relevant statements the client made about the ulcer This referral would be appropriate. 3. A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. 2. Correct: The LPN/LVN can monitor for behavioral changes and can look for potential safety hazards. Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. Assessing this client and titrating the diltiazem requires the skills of an RN. d. Services are centered in long-term care facilities, a. d. Bend at the knees when picking up an object, 99. c. Malpractice Covering open wounds will help to decrease bacterial exposure until the registered nurse or primary healthcare provider can assess and treat each wound. Clients are frequently admitted to a medical unit with a diagnosis of seizures and prescribed an anti seizure medication. Provides day to day direction and supervision to assigned direct patient care staff. Correct: The medical nurse can be assigned to this client. Speak to the UAP to determine what happened with the feeding. c. Blood-tinged urine c. I'll wear low heeled shoes from now on The assignment process requires constant evaluation and reevaluation of information and priorities. Involve the client in their plan of care. Select all that apply A client with fibromyalgia reporting generalized pain of 7 out of 10. 5. Review a low-sodium diet for a client who has hypertension. Sit side-by-side with the client Correct: Nurses must immediately report all client care issues, concerns or problems to the supervising nurse, the primary healthcare provider and/or the performance improvement or risk management department. 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.
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