The nurse is working in a team nursing model of care under the direction of an RN. Which action demonstrates an understanding of the LPN/LVN role in relationship to the RN?
1. The nurse performs a complete assessment of the client to determine plan of care.
2. The nurse determines the nursing diagnosis appropriate for the client.
3. The nurse consults the RN when a new problem with the client is identified.
4. The nurse asks the RN to perform wound care on the client.
3
Rationale 1: When a new problem is found, the LPN/LVN notifies the RN so that the plan of care can be adjusted. The LPN/LVN performs wound care for the client, and does not need to consult the RN unless the wound changes, the LPN/LVN is not certain of how to proceed, or assistance is required. The RN is responsible for nursing diagnosis and complete assessment.
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The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the nursing diagnosis risk for Perioperative positioning injury?
a. Patient will deny numbness or tingling in extremities after surgical procedure. b. Patient will maintain urine output of at least 30 mL/hour during and after surgery. c. Patient will maintain elastic skin turgor as well as moist tongue and mucus membranes. d. Patient will have no emesis and deny nausea following arousal from general anesthesia.
Getting accurate information from a patient during admission is an important job for the nurse recording this information. The answers to which admission questions will help form the best plan of care for the patient? (Select all that apply.)
a. How sick is the patient? b. What medication procedures will the patient require? c. Does the patient know you are an LPN/LVN? d. What special concerns or cultural beliefs does the patient have? e. Does the patient have health insurance?
In addition to standard preoperative assessment activities, patient preparation for coronary angiography also includes:
a. ECG, CXR, full blood count and coagulation studies, baseline neurological assessment, shaving both groin regions, plus the patient must be fasted. b. ECG, +/– CXR, full blood count and coagulation studies, baseline assessment of all peripheral pulses, shaving both groin regions, plus the patient must be fasted. c. ECG, +/– CXR, full blood count, baseline assessment of all peripheral pulses, shaving the right groin region, plus the patient must be fasted. d. ECG, +/– CXR, full blood count and coagulation studies, baseline assessment of all peripheral pulses, shaving both groin regions, the patient does not need to fast as the procedure is performed under a local anaesthetic.
Which patient statement would lead the nurse to suspect unsuccessful completion of the developmental task of infancy?
a. "I have very warm and close friendships." b. "I'm afraid to allow anyone to really get to know me." c. "I'm always absolutely right, so don't bother saying more." d. "I'm ashamed that I didn't do things correctly in the first place."