a charge nurse is making client care assignments a charge nurse is making client care assignments

A nurse is orienting a new assistive personal (AP) to the unit. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. c. Face shield Correct. 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. 4. and 16 g of fat. 2. A. Gather supplies to prepare room for isolation. a. I'll sit with my knees lower than my hips Incorrect: This is doing research, which requires the research process be implemented, including appropriate approval. An Advance Directive includes a Living Will and a Medical Power of Attorney. Could you try contacting a support group 3. The client asks about his medications and their effects. The nurse has received the change-of-shift report. There is a possibility that a hypothermia blanket may be prescribed. A written report of the incident is completed by the nurse and turned into the appropriate person (generally the performance improvement department). Correct: The best first action for the nurse is to identify a problem, and follow up with the appropriate person. Select all that apply b. This may result in several health problems including arrhythmias, an enlarged heart, heart failure, infections and bleeding. Talk to each nurse about concerns related to assigned clients. 3. Incorrect: A colostomy client with diarrhea will have a lot of drainage requiring frequent emptying of the colostomy bag. 1. c. I suggest you talk with a mental health counselor about your concerns d. Remove tea and coffee from meal trays, b. b. An adolescent client post appendectomy reporting pain. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? 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. b. The charge nurse must triage and assign clients to appropriate staff. 2. Which task is appropriate for the nurse to delegate to the experienced nursing assistant? It's unfortunate that I have to be in the hospital for this treatment (TENS units are portable; they can be used at home), 45. INCORRECT 3) Review a low-sodium diet for a client who has hypertension. Which of the following tasks should the nurse delegate to assistive personnel (AP)? A nurse removes an indwelling urinary catheter that an older client has had in place for 2 days. Based on a concept analysis of the charge nurse role, the author looks at a theory-gap analysis regarding how patient a 2. A nurse is caring for a client who is postoperative following abdominal surgery. Warm the feeding solution to the body temperature which client would be an appropriate care assignment for this lpn? c. Complete an incident report b. Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Relief of urinary retention The first client needing the nurse's attention is the one reporting a headache and has a fruity odor to their breath. a. Select all that apply There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. c. Make sure the client has an intake of 2,000-3,000 mL of fluid/day The nurse cannot assign assessment and evaluation of the nursing process to the UAP. 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. Client with a T-5 spinal cord injury beginning rehabilitation therapy. 2. The surgeon initially prescribes a clear liquid diet. The client is getting better. 1. Incorrect: This is a nursing responsibility and the best practice committee is the best place to begin. As part of an annual physical examination a nurse is preparing a client to undergo a chest x-ray. 3. b. Grape juice Two nurses lifting the client under the shoulders 3. 1. b. The nurse can accept the assignment, documenting your personal concerns regarding working conditions in which management decides the legitimacy of employee's personal concerns. 4. . 1. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. When the stomach does not make enough intrinsic factor, the intestine cannot properly absorb vitamin B12. 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. Besides, a charge nurse is a leader on the floor and should possess . This documentation should go to your manager. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. Elderly client who fell and fractured the left femoral neck. 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. 3. 1. "Please explain what you mean by the word 'nervous'.". What task would be appropriate for a nurse caring for a client diagnosed with gastroesophageal reflux to delegate to an unlicensed assistive personnel (UAP)? Incorrect: A lumbar puncture involves removing cerebrospinal fluid from the subarachnoid space to diagnose specific diseases or the presence of bacteria. Compartment syndrome could be developing which can impede circulation and cause nerve damage. Correct: The LPN is being floated to a specialty floor and appropriate assignments would include clients who are stable. c. Raised toilet seats b. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. a. Turn on local news for up-to-date information on the train derailment. Which of the following activities should the nurse perform in this zone? Incorrect: This group of clients needs specialized care. Ask the primary healthcare provider to suggest the best oral care procedure. d. To identify delayed gastric emptying, a. Auscultate breath should at least ever 2 hr (priority action the nurse should contribute to the plan of care when using the ABC approach to client care in auscultating breath sounds to determine the client's need for suctioning; with inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea), 43. The client reports constipation for 4 days which may be an indication of worse problems. c. Depression The LPN/LVN can reinforce teaching. Correct: The client may be experiencing a myocardial infarction and requires further assessment. _________________ (magnanimous), a. generous 2. Nursing questions and answers. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Make referrals to community services. 2. Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? a. 1. What action should the nurse implement first to ensure client safety? A nurse is teaching a client about the physical effects of chemotherapy. b. Assigning tasks to an AP Incorrect: The nurse can measure vital signs; however, agency policy usually states that UAP can perform this task also. 4. The charge nurse on the postpartum unit is making assignments. Open communication and brainstorming sessions in which staff can freely share thoughts or ideas creates a positive work environment while helping decrease dissatisfaction. A nurse is caring for an older client who is at risk for skin breakdown. 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. e. The urge to move the legs when trying to sleep, 66. A client requesting assistance packing his belongings for discharge later today.. Respite care allows the primary caregiver time away from day-to-day care responsibilities Which of the following of Erikson's developmental stages should the nurse consider in the planning? Incorrect: This will take a lot of time and is best initiated from the "best practice" committee. This client is stable and predictable. Which of the following tasks should the charge nurse reassign to a licensed nurse? Feedback c. Check to see if the suction equipment is working The nurse would then start the 24 hour urine once the 1st void has been discarded. The charge nurse might not have realized all the responsibilities of taking this team of clients. This is an elderly client who is a new admit. c. Blood-tinged urine Both of these clients are terminal. 1. A nurse is caring for a client who frequently attempts to remove his IV catheter. Which of the following tasks should the nurse delegate to unlicensed assistive personnel (UAP)? Which of the following nursing statements indicates the nurse understands when discharge plans should be implemented? 3. Something new could have occurred with the clients, making the assignments too heavy. 2. 1. c. Offering false reassurance c. Shivering A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. 2. Incorrect: Emergency room nurses deal with life threatening emergencies but are not specialized in the care of clients with preeclampsia. a. b. This service focuses on teaching the primary caregiver to meet the client's needs A nurse who is breastfeeding her 4 month old. 4. Complete a neurological check (appropriate nursing intervention when a client displays sudden confusion). Provides safe, effective delivery of patient care in . A nurse instructs a female client about collecting a midstream urine sample. Based on this information,what should the nurse do? This should not be delegated to the LPN/LVN. Assist a client to ambulate using a gait belt a. Reach around the pack and open the top flap away from the body b. Wash the tablet off with alcohol and place it in a clean medicine cup For which of the following tasks should the nurse wear protective eye equipment. Elderly clients have special fluid and electrolyte issues after a fall. 2. Monitor client for pain while assisting with ambulation. a. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. What should the nurse do first? d. Otorhinolaryngologist, c. Irrigating a client's abdominal wound c. Include intact skin at the wound edges in the culture The nurse is focusing on which of the following elements of the communication process? Which of the following explanations should the nurse provide? c. They tend to use more verbal communication The client is receiving IV fluids through an IV catheter inserted in the basilic vein on the right forearm. b. Urinary frequency for several days 1., 2., 4., & 5. Hold the penis at a 30 to 45 degree angle when inserting the catheter d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. The third client would be the one needing a dressing change. 1. The supervisor can only send one LPN/LVN to the floor. a. Bathtub with rails Correct: A thoracentesis is performed to remove fluid from the pleural cavity and improve the client's respiratory status. Electric cords behind the furnitrure 1, 3 & 5. 4. During lunch, Robin jotted a letter to Amy and signed it, "your friend, Robin.". 4. 4. Select all that apply. 4. Select all that apply Anyone over age 18 can have an Advanced directive. c. Respite care helps relieve pain and promote comfort Select all that apply. 2. 2. 5. Remind the client that a signed informed consent form is a legally binding document leadership management of care nurse on unit is providing care for group of clients. Which of the following actions should the nurse take prior to administering the tube feeding? The nurse prefers to check all vital signs on all clients. Teaching insulin self administration to a diabetic client. The nurse is planning care for a client admitted with Alzheimer's Disease. Which of the following instructions should the nurse include? 2. Which of the following actions is an example of a violation of confidentiality? c. Palpating for pedal edema If you give the magnesium citrate, which is a laxative, what will happen? Which of the following info should the nurse include? Notify the charge nurse of the observations. Nothing will get passed the complete blockage. The nurse did not trust the new UAP. 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. 2. c. The client's culture Incorrect: A client who has a spinal cord injury and is in rehabilitation is still alert and able to make decisions. (Select all that apply.). 2. Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. 8. 4. c. Distended bladder Stand directly in front of the client nursing brain nurse sheets night documentation hour rotation sheet icu care assessment charting plan nurses assignment patient shift report rn. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. The nurse should initiate a referral with which of the following members of the interprofessional health care team? 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? This client would be the priority based on the need for prompt recognition and treatment of the neutropenia and signs of infection present. When a family member asks how respite care can help, which of the following responses should the nurse provide? e. Suctioning a client's new tracheostomy tube, 93. The client should be assessed first to rule out respiratory difficulty and hemorrhage. To remove gastric acid that might cause dyspepsia This task cannot be delegated to the LPN/LVN. Those residing in long term care facilities benefit greatly from time spent with family or even older friends. 1. 3. 4. Incorrect: Although this nurse is working on the postpartum unit, did you recognize the length of experience? 3. A nurse is caring for a client who has a wound infection. A two-hour limit on visits discourages quality time. b. A nurse is assessing a client who is experiencing prostatic hypertrophy. 3. Correct: All facilities are required to develop a disaster plan, per JCAHO (Joint Commission on Accreditation of Healthcare Organizations) regulations, though the plans vary. It can develop suddenly or slowly and tends to worsen with time, unless the cause is found and treated. Report of feeling pressure Assist client to brush and floss teeth. Removing the abdominal dressing a. I'll urinate a little then stop Find a mentor Most nurses learn to make nurse-patient assign-ments from a colleague. b. Which of the following actions should the nurse take regarding informed consent? c. Paraphrasing 3. c. Nonfat milk e. Throw rugs, 40. d. What have you done in the past to cope with this issue? is a new graduate in orientation. Notify the primary healthcare provider. Only a plain enema or soap enema can be given by the UAP. Which nursing intervention should the charge nurse implement? c. Surgeon (the health care provider who will perform the treatment or procedure is responsible for obtaining informed consent from the client). A nurse is assessing a client who has narcolepsy. c. Helping the client into the shower Assist a client to ambulate using a gait belt d. Providing information, a. 1. Evaluate pain relief after narcotic administration. 1. d. Go to employee health services, b. Feed a client that had a stroke 3 months ago. 2. Which of the following findings indicates that the client is meeting this goal? a. This client could be transferred with traction still maintained. Headache following this procedure is a potential side effect and would not be the priority concern for the nurse. Which referral would most likely be appropriate for the nurse to make? d. Left forearm, b. a. Comatose client with end stage chronic obstructive pulmonary disease. 4. (Select all that apply.) 3. Incorrect: The charge nurse does not have to assess every client. Which of the following responses should the nurse make? Drag and Drop the items from one box to the other. A nurse is engaging in relationship counseling with a male client. A client with atrial fibrillation currently on a diltiazem drip. 5. c. We administer all medications intravenously to clients in this unit A charge nurse is making assignments for an oncoming shift. Because the charge nurse observes and weighs . 3. Which task would be appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? 1. 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. c. Contact the provider to question the dosage (when a nurse believes there is an error in a prescription, the nurse must question the provider). You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. b. c. Review a low-sodium diet for the client who has hypertension A charge nurse is planning a room assignment for a client who has a productive cough, a questionable x-ray, and a positive Mantoux test. a. Bathe a client who had an amputation 2 days ago The RN with 5 years' experience in the Labor and Delivery unit. c. I will begin upon the client's admission to the facility Demonstrate principles of collaborative practice within the nursing and healthcare teams fostering mutual respect and shared decision-making to achieve stated outcomes of care. Incorrect: The nurse is responsible for monitoring a client. 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. Schedule visiting times in two-hour increments so clients are not overwhelmed. Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. 3. 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. Select all that apply. d. Complete an incident report, 70. Incorrect: Although this nurse may be accustomed to caring for clients in acute situations requiring a higher level of care, this nurse is not familiar with caring for clients with preeclampsia. Yes! 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. c. I should purchase a carbon monoxide detector for my home Female client stating she has been raped. Speak to the UAP to determine what happened with the feeding. Which of the following findings should the nurse identify as a safety risk? b. Incorrect: This will take some time and would be best accomplished by sitting with the family to discuss options. b. b. The charge nurse should be informed that the delegated intervention is not appropriate according to the state's Nurse Practice Act. a. Wears a gown when entering the room of a client who requires contact precautions The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia. a. Gloves c. Lock the medication in a room and finish preparing it after returning from the emergency b. A nurse is teaching a client who has a history of falls about home safety. 2., 3. 5. Which observation of denture care by the unlicensed assistive personnel (UAP) would require the nurse to intervene? a. I'll apply ankle to my ankle today and tomorrow d. Proceed with the preparation of the patient's surgical procedure, 15. a. Personal liability coverage is not mandatory, but you should consider purchasing your own coverage Which action by an unlicensed nursing assistant would require the nurse to intervene? Correct: The unlicensed nursing assistant should not turn tube feedings off or on. e. Lemon gelatin, d. Use soap and water to wash the catheter after each use, 33. 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. Incorrect: A client scheduled for surgery after a mastectomy is still able to make decisions. If you are new to this challenge, try these eight tips as a guide for making nurse-patient assignments. There are potential problems in Options #1, 2, 3, and 4 and should be questioned and corrected. 3. A nurse is preparing a sterile field. Incorrect: An Advance Directive is a written, legal document regarding preferences for medical care should a person become unable to make medical decisions. c. Discard any residual gastric contents a. I will keep my walker at the end of my bed Oral surgeon A client with fibromyalgia reporting generalized pain of 7 out of 10. 1. A nurse who is on hormone replacement therapy. a. d. Do you think crying will help? Incorrect: This prescription is written correctly. The client states, "I am so nervous about what the doctor might find during the test." 2. Normally, red blood cells are flexible and round, moving easily through blood vessels. d. Resistance is evident as subgroups form in this stage, c. Discard the tablet and obtain another dose of medication, 35. Incorrect: The nurse manager is aware that health care facilities often face both political and financial issues that impact staff and clients simultaneously. A client with diabetes admitted for debridement of a foot ulcer. c. Visual observation for nonverbal signs of pain 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 . Select all that apply. b. Incorrect: This group of clients needs specific teaching. c. Interpersonal (interpersonal communication is face-to-face interaction with another person.