A nurse working on the pediatric oncology unit is beginning the shift and has received report which included some new laboratory data for the clients. Take several shallow breaths during the procedure a. I'll provide more stimulation in his environment Call the family of a client suffering from dementia to discuss long term care placement. d. Apply cornstarch to keep the skin dry, b. Wash the area of the puncture thoroughly with soap and water (the greatest risk to this client is injury from any bloodborne pathogens on the needle therefore the first action the nurse should take is to provide immediate first aid), 28. The key word in the stem is first. A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following health care professionals is responsible for obtaining informed consent from the client for the procedure? c. Distended bladder A nurse is caring for a client within the intimate zone of the client's personal space. During exacerbation, the client will have many diarrhea stools. (Select all that apply.). Remember, pick the killer answer first! b. 3. d. Counting radial pulse, 100. Changing a colostomy bag. It is quicker to administer medications intravenously in the hospital A nurse is caring for a client who is postoperative following an appendectomy. Describe the types of machining operations that can be performed on a lathe. Report from the night shift nurse for one client included the recent development of the following findings: BP 150/100, proteinuria, severe headache, blurred vision, and abdominal pain. Report of feeling pressure a. Incorrect: Passive ROM is performed with paralysis and can be delegated to the UAP. Incorrect: The treatment of hypertension is critical in the management of a post hemorrhagic stroke. The nurse delegated feeding of a client to the unlicensed assistive personnel (UAP). When handling any disaster, a facility must have a "command center" that is operated by outside personnel such as a Fire chief, Police, Swat or other outside emergency persons. 2. Prior to turning feeding back on, tube placement needs to be verified. 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. 1. The client can indicate desire for Do Not Resuscitate (DNR). 2) Assist a client to ambulate using a gait belt. Therefore, measures should be instituted to reduce the risk of the development of an overwhelming infection and sepsis. When determining if the client is eating a well-balanced diet Autonomy vs shame and doubt Which region of the tRNA pairs with mRNA? The RN with 10 years' experience pulled from the ER. Which of the following actions should the nurse take? 2. (Select all that apply.). c. Gender A client post pacemaker insertion, awaiting discharge instructions. d. Counting radial pulse To focus on effective learning with this client, which of the following interventions should the nurse use? e. Feed a client who had a stroke 3 months ago, 32. What action should the nurse take after mistakenly administering the wrong medication? A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. c. Leave a nightlight on in the client's room Which of the following indications should the nurse include? Drag and Drop the items from one box to the other. The RN will also need to be in communication with the assisted living facility to ensure that they have are a support system for the patient and her follow up care with her pacer. However, since the new UAP's competency level is not known, the nurse does not delegate this task for the safety of the client. c. We administer all medications intravenously to clients in this unit 6. 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. The word or phrase that you choose must express roughly the same meaning as the italicized word in the passage. c. Providing anticipatory guidance to a client in crisis 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. Which of the following types of communication breakdown does this response represent? 3. Removing the abdominal dressing Incorrect: The charge nurse cannot change the scope of practice for the LPN by evaluating the intervention. Check environment for potential safety hazards. Plan all care to be completed in early morning to allow afternoon for visitation. b. & 3. 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. a. 76. Incorrect: First, the local news does not necessarily have the most accurate information on the disaster. Refuse the delegated intervention. Incorrect: Restricting visitation to two hours is not appropriate, particularly for families traveling long distances to visit a client. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation? 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." 1. Which of the following actions by the nurse is considered an indirect nursing care activity? Give magnesium citrate 296 mL at 3 PM today. A lack of rapid eye movement (REM) sleep The assignment process requires constant evaluation and reevaluation of information and priorities. Incorrect: It is out of the UAP's scope of practice to administer medication. The nurse in a long-term care facility is making client care assignments for unlicensed assistive personnel (UAP). Incorrect: The client with fibromyalgia is reporting a pain level that needs to be addressed and the client will likely require pain medications. Incorrect: The first void of a 24 hour urine is discarded and can be delegated to the UAP. Discuss the issue with the leader of the "best practices" committee. Client with arthralgia who is receiving regularly scheduled pain medications and has warm compresses prescribed. A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. c. Can you tell me why you chose me? Which prescription should the nurse question and have corrected? a. It can result in muscle spasm and tissue damage. a. the nurse responds, "don't worry, no one will harm your family." c. Discard the tablet and obtain another dose of medication Select all that apply a. Hypotension 3. What is the major histological difference between thick and thin skin? A nurse is admitting a client from a long-term care facility. a. Auscultate breath should at least ever 2 hr The nurse suggest that the family might need to respite care services. Ask the charge nurse to evaluate the intervention. The charge nurse is making client assignments for a neuro-medical floor. c. Face shield The RN requests reassigning at least one of the clients to another nurse. Turning off continuous tube feeding to reposition a client, then turning the feeding back on. Because a scope is inserted through the urethra for this procedure, the client may experience burning or frequency immediately following this test. 3. 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. Suggest splitting the shift with another nurse. 2. 4. A nurse is prioritizing care for two clients at the start of the shift. This should not be delegated to the LPN/LVN. Demonstrate the use of clinical reasoning in prioritizing and evaluating the delivery of client care. Correct: Communication is important in delegation, as is follow-up. It would not be appropriate to overload this new employee with extra work. b. b. Correct: Positive feedback is an effective communication tool that improves the workplace environment and encourages individual achievement, particularly in challenging situations. Bargaining 2. _____The house that we lived in for nine years has been sold. Confrontation should occur in the presence of a charge nurse or supervisor. When staff do not feel vested in any new process, there is a sense of underappreciation. Placing the traction weights on the bed to transfer the client to x-ray. Soaking the dentures in hot water Keep a personal copy of this documentation, provide a copy to the immediate supervisor, and send a copy to the Local Unit Officer. Which of the following statements should the nurse identify as an indication that the client needs further instruction? Which of the following pieces of PPE should the nurse remove first? Where on the body is each type of skin found? d. Identifying the client by name when making a referral for home health services, 30. The other options may be correct but are not the best first action. This client is stable and predictable. b. I will begin once the client's discharge order is written 4. Which of the following instructions should the nurse include? d. Talk with the client's partner, b. A nurse is caring for a client who has had an allogenic hematopoietic stem-cell transplant. Which of the following nontherapeutic communication techniques is the nurse using? d. The nature and invasiveness of the surgical procedure, d. The nurse has already considered alternatives to restraints, 89. A nurse is caring for a client who has emphysema and has difficulty with mobility. Asking for an explanation Assigning this nurse to the newborn with CMV would put her unborn baby at high risk for life-long defects and even death. a. Twist at the waist when she moves an object to one side a. 1. Select all that apply. Elderly clients have special fluid and electrolyte issues after a fall. The client says, "go away, no one can help me." Irrigate a client's ear canal. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. Request that the nursing assistant obtain equipment for the client's care while the RN talks with the client and the family. 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. Which of the following items should the nurse include on the lunch tray? Pernicious Anemia Society The charge nurse asks the nurse who works in a state where mandatory overtime is legal to work an additional 8 hours of mandatory overtime. b. Grape juice A nurse asks a client to share personal stories. A client with exacerbation of COPD reporting dyspnea. A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. There may be a good reason that the tray was not served. A nurse is creating a discharge plan. a. a. I'll urinate a little then stop c. The nurse may serve as a witness to informed consent for organ donation c. Use intermittent eye contact The charge nurse on the postpartum unit is making assignments. c. Complete an incident report c. Check to see if the suction equipment is working 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. Monitor for behavioral changes. 4. a. Denial The client then states, "I have changed my mind and do not want to have the procedure done." It results in an exchange of ideas, problem solving expression of feelings, decision making, and personal growth). 3. Which of the following instructions should the nurse include? 1., 2., 4., & 5. Provides safe, effective delivery of patient care in . There is a possibility of rejection, which means close assessments and evaluations are needed by the RN. b. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96. Making patient assignments is an important charge nurse role that lacks theoretical support and practical guidelines. Each ROM movement should be repeated 5 times during the session. 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. The second client that needs to be seen by the nurse is the client having weakness, a sign of hypoglycemia. 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. Client assignments are based on client acuity and nurses do not necessarily have the same number of clients. Post-surgical pain is expected and without further parameters, no determination can be made regarding this client. a. 32-36, Winningham's Critical Thinking Cases in Nursing, Final Exam Review -Missed QuestionsE5-Multi. The RN who has worked in Labor and Delivery would have knowledge and experience caring for clients with preeclampsia.