Incorrect: Discussing the assignment with another LPN is delaying the client's needed intervention. The client states, "I am so nervous about what the doctor might find during the test." c. Discard the tablet and obtain another dose of medication An LPN/VN has been floated to the emergency room following a chemical plant explosion. 4. Incorrect: A UAP may not remove and change surgical dressings, which would involve assessment and further education. Correct: A LPN should be able to care for a client with arthralgia who requires pain medication on a regular schedule and is receiving warm compresses. b. Dons gloves to empty a urinary drainage device Stand directly in front of the client A nurse is assessing a client at a follow-up clinic for acute low back pain. A charge nurse is making client care assignments. c. Depression Vital sign measurement Incorrect: The administration of parenteral pain medications is not in the scope of practice for the LPN/LVN. Incorrect: This group of clients needs specialized care. Incorrect: Volunteering to take a client would add more work to the charge nurse when this might not be necessary. Remember if you work overtime, fatigue is not a viable reason for a error and will not stand up in court. 3. d. Voided 30 mL frequently 6. Place the pack on a sterile work surface Determine which personnel could be sent to the command center. Left upper forearm 2. 3. b. Wash the tablet off with alcohol and place it in a clean medicine cup Review a low-sodium diet for a client with hypertension. Incorrect: The RN is responsible for assessment and evaluation of clients. Provide an adaptive feeding device for the client 3. A nurse is caring for an older adult client who has a fractured hip and will require rehab care. 2. A nurse caring for a client is using active listening skills. A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. The best practice committee utilizes current research in their recommendations. Which of the following client statements should indicate to the nurse the need for additional teaching? The nurse should not lecture, scold or argue with the float nurse. a. Which client should the nurse see first? b. 2. This action is a defensive intervention, and does not address the quarrelsome behavior. 3. a. If the LPN notes any serious bleeding situations, it would need reported immediately to the RN. 2. A nurse who is breastfeeding her 4 month old. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? Besides, a charge nurse is a leader on the floor and should possess . A nurse is discussing the norming stage of the group development process with a student nurse. A nurse is caring for a client who is postoperative. Correct. 1. These individuals are selected by the charge nurse, and do not have to be nurses. 2. 4. Encourage the client to be more cooperative. This client is eating a simple carb snack, but the nurse needs to check the client's blood glucose level to see if the snack has helped. The RN is assigned to care for an unemployed 26-year-old woman, newly diagnosed with acquired immunodeficiency syndrome (AIDS). Two hours . The first client the nurse needs to assess is the elderly client admitted 30 minutes ago with reports of constipation for four days. e. Throw rugs, d. I will take my medications at the first sign of an attack, 41. Which of the following responses should the nurse make? c. Changing a dressing, 78. There may be a good reason that the tray was not served. d. Establishing the client's secondary medical diagnoses, b. The client with cystitis is stable and has a predictable outcome. If the client is unstable, the nurse would retain the role of measuring the vital signs. A copy of select parts of the medical recording, according to facility policy, is another form of communication that will support continuity of care. b. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. A nurse is teaching a client about the physical effects of chemotherapy. b. Correct: The nurse manager is aware that open communication with staff is vital to increase workplace satisfaction and staff retention. So, the UAP can assist a client to brush and floss teeth. This service began with the client's admission to the hospital 1. c. Face shield Try different methods of oral care on unresponsive clients to see what works best. 1. Select all that apply. b. c. Distended bladder Skill level and scope of practice of each staff member, Exit HESI (Actual hesi hints), EXIT HESI 2, Julie S Snyder, Linda Lilley, Shelly Collins. A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has a benign prostatic hyperplasia. Which of the following types of communication breakdown does this response represent? Which of the following actions should the nurse take? 3. a. Of my three brothers and sisters, my sister Giselle has the best sense of humor. b. b. 4. The best practice committee works to improve clinical practice based on current research. Speak using his usual tone of voice Incorrect: Sickle cell anemia is not caused by folic acid deficiency, so this client would not need a referral to this society. CORRECT: The client is potentially experiencing symptoms of an impending seizure, which can include seeing halos around lights or detecting odd smells. c. Paraphrasing Administer sodium polystyrene sulfonate enema. Incorrect: Most adults have already been exposed to the virus and are not at risk for adverse effects of the infection. Which of the following statements should the nurse make? c. Review a low-sodium diet for the client who has hypertension c. Environment b. eminent 4. Assist a client to ambulate using a gait belt 2. 2. 1. Removing the client's dentures 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. 4. An LPN/VN has been floated to the emergency room following a chemical plant explosion. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. Monitor for GI upset 30 minutes after meals. A charge nurse is making client care assignments. Correct: The client may be experiencing a myocardial infarction and requires further assessment. Talk to each nurse about concerns related to assigned clients. Places the soiled linen in the floor before bagging it c. Respite care helps relieve pain and promote comfort An adult (18 years or older) can create an advanced directive. 4. As a charge nurse, you're a frontline leaderthe first reflection of your organizationand you need to ensure you are meeting the organization's goals and values. 3. c. Complete an incident report 2. 5. 1. What is the appropriate assignment? Administering IV pain medication to a two day post op client. 2. However, providing care for missing teeth would also be within the LPN scope of practice. a. Return any fresh linen not used for a client to the linen supply area c. Assist the client to the floor and begin mouth-to-mouth 3. Select all that apply After making initial assessment rounds on assigned clients in the morning, the RN tells the charge nurse that the clients are too difficult. 5. 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). d. Swab an area of skin away from the wound to identify the usual flora, a. Elicit info from the client (obtaining info from the client is a component of orientation phase), 57. Incorrect: Informing is the same thing as teaching. 1., 2., 4., & 5. It is within the LPNs scope of practice to administer antibiotics. 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. b. I can detect the presence of carbon monoxide by a metallic odor 1. Relief of urinary retention You get this vitamin from eating foods such as meat, poultry, shellfish, eggs, and dairy products. Gather supplies to prepare room for isolation. 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. Feed the client after warming the food. Dexlansoprazole 30 mg PO daily. 4. A nurse wants to find out a better way to perform oral care on unresponsive clients. c. Document in the client's medical record that she completed an incident report Which of the following tasks should the nurse delegate to assistive personnel (AP)? 1. 3. Notify the nursing supervisor of the situation. Refuse the overtime assignment, being prepared for disciplinary action. Who should the nurse see first? The client must understand the need for restraints Nothing by mouth (NPO). a. a. I will keep my walker at the end of my bed 2. a. Use double bagging to remove soiled linen from the client's room 3. 1. Which client should the nurse assess first? Female client stating she has been raped. Sudden attacks of sleep A. nurse is caring for a client who is not cooperating with his care and demonstrates defiant behavior. Place in priority order. Ask the client to perform a return demonstration of insulin injection 3. Although this is a correct thing to inform the client, this teaching should be done by the RN and not delegated to the UAP. A nurse enters an older adult client's room to insert a saline lock. c. I will cover the catheter so he cannot see it 3. This perceived lack of control can create distrust and frustration among personnel, ultimately impacting client care. You would be jeopardizing the limb of this client to take the time to do discharge teaching for the client waiting to go home. A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. A charge nurse is making client care assignments. 4. 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. Assist client to brush and floss teeth. These areas require the expertise of an RN and would not be appropriate for an LPN/LVN. a. Correct: An LPN/LVN's scope of practice includes tasks such as wound care. c. I will begin upon the client's admission to the facility a. 3. b. Electric comes from the Latin word for amber, a substance which readily takes a static electric charge. Change the subject when the client behaves defiantly Which tasks would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? Client reporting a headache and has a fruity breath. Only the state Board of Nursing can legally determine the LPN's scope of practice. 4. 1. a. Lumbar puncture reporting a headache. a. 1. The nurse should not be assigned to provide care if impairment is suspected. Make referrals to community services. The RN requests reassigning at least one of the clients to another nurse. A nurse is providing discharge teaching for a client who requires home oxygen therapy. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. Announce the new changes at the monthly staff meeting. 2. b. I'll do exercises that strengthen my abdominal muscles 4. c. Washes and rinses her hands for 10 seconds The nurse is using which of the following therapeutic communication techniques? "The client is weak on the right side, so please assist the client with dressing . Incorrect: Dealing with a client's emotional state requires a formative evaluation to gauge readiness and requires the knowledge of the RN. d. Droplet, d. Bend at the knees when picking up an object, 98. Prepare a list of clients who could quickly be discharged or transferred. Briefly assess every client. 1. Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. 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. This client is at a high risk of infection. Correct: Assisting clients with activities of daily living are within the UAPs scope of practice. c. The chances of a malpractice suit are minimal as long as you follow our policies and procedures 3. 5. Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. a. I'll urinate a little then stop Bargaining 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. The nurse should immediately assess this client, implement seizure precautions and remain with client for safety. c. I will inspect my crutches everyday for signs of wear 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. c. Hand-off technique Complete a client assignment sheet for the oncoming staff. 5. 1. This client is not the nurse's first priority. Assuming that dissolved reactants and products are present at 1 M concentrations, which of the following reactions are nonspontaneous in the forward direction?