The charge nurse's best response is to first obtain the needed information to make the best decision. The nurse received a client following surgery 8 hours ago. Which of the following actions should the nurse take regarding informed consent? d. Voided 30 mL frequently Where on the body is each type of skin found? 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. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Compartment syndrome could be developing which can impede circulation and cause nerve damage. 4. A nurse is discussing the norming stage of the group development process with a student nurse. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 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. Drag and Drop the items from one box to the other. A Medical Power of Attorney is a type of Advance Directive that appoints a health care agent to make decisions on the client's behalf when the client is unable to do so. The expected standard of care was strict bed rest), 96. INCORRECT: Although the vascular status of the foot will need to be assessed, there is no indication if the debridement has been completed yet. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? The client was lying on the floor next to his bed (nurse should document what they actually see), 68. In this situation, it is not a matter of the nurse preferring to take all the vital signs, but the nurse needs to know the competency level of the UAP before delegating this task. c. Discard any residual gastric contents (Sclect all that apply) A. Bathe a client who had an amputation 2 days ago. a. Broth Evaluate pain relief after narcotic administration. (Select all that apply) 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. b. 1. Which of the following infection-control precautions should the nurse use caring for this client? A special protein, called intrinsic factor (IF), binds vitamin B12 so that it can be absorbed in the intestines. It can result in muscle spasm and tissue damage. e. Assessing a mole on the client's shoulder, Latin GCSE Vocab - 1st and 2nd Declension Adj, NUR 204 ATI Psychosocial Integrity Ch. 1. Most likely, the clients will be aware of the disaster already, and further information could be confusing or frightening. b. b. Describe the types of machining operations that can be performed on a lathe. c. When asking the client how he completes his ADLs Soaking the dentures in hot water Draining of the bag is a routine toileting procedure for the colostomy client and.is within the scope of practice for the UAP. c. Check to see if the suction equipment is working 2. Which of the following of Erikson's developmental stages should the nurse consider in the planning? b. Speak using his usual tone of voice A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. 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. a. Incorrect: The RN is responsible for teaching. Twist at the waist when she moves an object to one side b. A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. It would not be appropriate to overload this new employee with extra work. which client would be most appropriate to assign a licensed practical nurse (lpn)? The RN with 5 years' experience in the Labor and Delivery unit. (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 d. Apply antiembolic stockings, d. I will place a bath seat in my shower to use when I bathe, 44. d. Motor impairment, 84. What was the rationale for this plan? c. I will cover the catheter so he cannot see it Incorrect: This prescription is written correctly. The nurse would then start the 24 hour urine once the 1st void has been discarded. What client should the nurse assess first? d. Breathing in carbon monoxide can cause headaches and nausea, c. Take the client to the bathroom every 2 hr (this establishes a regular pattern of toileting and the client learns to trust that the staff will place value on his bladder-training needs), 59. c. Visual observation for nonverbal signs of pain (Select all that apply.) During report, the nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. This client needs careful monitoring and specialized care. 3. Incorrect: Atrial fibrillation places the client at risk for blood clots. a. Prospectors are considering searching for gold on a plot of land that contains 1.31g1.31 \mathrm{~g}1.31g of gold per bucket of soil. Provide positive feedback to the UAP. The nurse is using which level of communication at this time? b. Client one day post kidney transplant. What is the appropriate assignment? A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. Which of the following info should the nurse include? Estimate the number of Calories in two tablespoons of peanut b. Comatose client with end stage chronic obstructive pulmonary disease. Hormone replacement does not affect the immune system and, therefore, this nurse is not at risk for infection from CMV exposure. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. A newborn is admitted to the nursery with a diagnosis of rule out cytomegalovirus (CMV). 3. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). The RN with 2 weeks' experience on the postpartum unit. A person can indicate they wish to be a DNR client if their heart stops beating or they stop breathing. Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. a. Complete blockage of the large intestine. However, providing care for missing teeth would also be within the LPN scope of practice. A cardiac step down unit has requested float staff because of multiple impending admissions. A nurse is caring for a client who has a hip fracture that requires surgical repair. Charge nurses have integral roles in healthcare organizations. b. 4. 1. the nurse responds, "don't worry, no one will harm your family." a. 1. 1. Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Which of the following instructions should the nurse give to the client prior to the procedure? a.) Only the state Board of Nursing can legally determine the LPN's scope of practice. The UAP can ambulate the client and can report to the nurse if the client states that pain is occurring but cannot monitor or collect data. d. Social conversation, a. 4. Which actions should be instituted by each unit's charge nurse? Nurses Report Sheet Template Nicu. The client then states, "I have changed my mind and do not want to have the procedure done." The RN with 10 years' experience pulled from the ER. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. A nurse is caring for a client in the orientation phase of the nurse-client relationship. c. I will make sure my visitors smoke outside c. Provide the client with a diet high in protein Incorrect: The RN is responsible for assessment and evaluation. Measure urine output when client voids. In which harmonic number n is the string vibrating? c. Interpersonal (interpersonal communication is face-to-face interaction with another person. Focus on the client's present circumstances instead of his personal stories The client is reporting anxiety, discomfort, and a feeling of bloating. Report of feeling pressure Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. The situation should be explored before bringing the supervisor in on the situation. b. c. Inflate the balloon when the urine flow stops A nurse is teaching a client about carbon monoxide poisoning. For which of the following tasks should the nurse wear protective eye equipment. 1. a. Incorrect: It is out of the UAP's scope of practice to administer medication. The charge nurse must triage and assign clients to appropriate staff. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. Incorrect: Aplastic anemia is a blood disorder in which the body's bone marrow doesn't make enough new blood cells. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? c. There is fluid leaking around the insertion site A new UAP is efficiently completing all daily assignments accurately and in a timely manner. Normally, red blood cells are flexible and round, moving easily through blood vessels. Which of the following approaches should the nurse use when using confrontation? b. c. Blood-tinged urine leadership management of care nurse on unit is providing care for group of clients. a. 3. Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 5. Pernicious Anemia Society This template is beneficial for nursing students and veteran nurses alike, and can be used in any unit. 2. A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. The nurse also needs to be aware of the color and amount of urine voided. Symbolic communication Learning Objectives for this assignment include: Apply the principles of delegation in the healthcare setting. c. Why are you crying? c. Lock the medication in a room and finish preparing it after returning from the emergency c. Distended bladder c. Hand-off technique 4. d. Water heater temp 54.4 C (130 F) Which of the following actions by the nurse is considered an indirect nursing care activity? 4. Encourage client to express grief related to loss of independence. a. Auscultate breath should at least ever 2 hr The first vital sign check was performed by the nurse. & 5. a. Which of the following client statements indicates an understanding of the procedure? Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. "Please explain what you mean by the word 'nervous'.". Which of the following actions should the nurse take? Perform catheterization when you recognize the urge to void Client diagnosed with gastroenteritis who reported 300 mL diarrhea stool x2 in the last hour. 2) Assist a client to ambulate using a gait belt. Document current functional status assessment Post-surgical pain is expected and without further parameters, no determination can be made regarding this client.