When assisting a client in learning how to use a cane, the nurse aid stands....
Answer: 4 Standing slightly behind the client at her weak side better enables the nurse aide to prevent falls. Choices 1 and 2 are incorrect because these distances are too far to safely catch the client if she falls or to support her. Choice 3 is incorrect because if the nurse aide is placed there, the client may collapse on her weak side.
When working with a client who has urinary retention, the nurse aide should expect that the client will...
Answer: 2 Urinary retention means that the client cannot urinate. The problem should be reported to the nurse as soon as possible. Choice 1 is incorrect; urinating in large volumes, also called polyuria, is indicative of a medical problem such as diabetes mellitus. Choice 3 is incorrect; urinating too frequently means that the client may have a problem such as a urinary tract infection. Choice 4 is incorrect; urinary incontinence is the accidental release of urine. It may happen in small amounts when someone coughs or sneezes, or regularly if someone has a medical problem. While choices 1, 3, and 4 are not correct answers, these problems should be reported to the nurse as soon as possible.
Aging-related hearing changes result in older clients gradually losing their abiity to hear...
Answer: 1 Age-related hearing loss, also called presbycusis, results in older persons gradually losing their abilit to hear high-pitched sounds. Choice 2 is incorrect; the ability to hear low-pitched sounds may mean that the client has otosclerosis, which is usually related to abnormal bone growth in the bones of the inner ear. Choices 3 and 4 are incorrect; a reduction in sound level and the inability to hear faint sounds can indicate hearing loss due to problems such as an ear infection or impacted cerumen (too much ear wax).
The best way to safely identify your patient is by...
Answer: 4 Checking a client's name tag is the safest way of assuring that you have the correct client. If you ask a client his name, and he is confused or has difficulty hearing, he may give you the wrong name. A confused client may also be lying in the wrong bed.
A client is on a bowel and bladder training program and has not had a bowel movement in three days. The nurse aide should...
Answer: 1 The nurse aide should report this problem because nurse aides cannot perform any of the interventions on their own. Nurse aides cannot give clients enemas without being instructed to do so by the nurse. They also cannot encourage drinking more fluids or give prune juice as a treatment on their own (and prune juice would be insufficient for this client).
The proper medical abbreviation for before meals is...
Answer: 3 The proper medical abbreviation for before meals is a.c., p.c. is the proper medical abbreviation for after meals, b.i.d. is the proper medical abbreviation for twice a day, and t.i.d. is the proper medical abbreviation for three times a day.
A client diagnosed with hypertension will most likely have a history of...
Answer: 2 Hypertension is the medical term for high blood pressure, so the client will most likely have this problem in his history, although it may now be controlled with medication. The medical term for low blood pressure is hypotension. The medical term for low blood sugar is hypoglycemia. The medical terms for high blood sugar is hyperglycemia.
A patient who has difficulty chewing or swallowing will need what type of diet?
Answer: 4 A mechanical soft diet is prescribed for clients who need a diet that is easy to chew, swallow, and digest. Choice 1 is incorrect; a clear liquid diet is usually prescribed for clients before medical tests, for clients who have nausea and vomitting or an acute illness, or for clients who have experienced trauma or surgery. Choice 2 is incorret; a low residue diet is prescribed for clients to reduce the frequency and volume of their stools. Choice 3 is incorrect; a pureed diet is prescribed for clients who have poor dentition, who are very frail, or who are in end-stage disease.
An elderly resident with Alzheimer's disease cannot find her room. How can the nurse aide help the client feel more independent?
Answer: 3 A familiar object can enable a client to find her room on her own, helping her feel more independent. Telling a client to stay in her room is restrictive and may be a violation of her rights. Choice 2 is incorrect because asking a roommate to do something for another client is inappropriate-it puts undue strain on the roommate and can create an unsafe environment for the client and the roommate. Choice 4 is incorrect because the client may lose the piece of paper or may be too confused at times to know what the number means.
How often should a patient's intake and output records be totaled?
Answer: 1 Intake and output are usually recorded every shift, as well as every 24 hours. Most agencies run on 8-hour shifts, not 12-hour shifts. When clients need more frequent observation of intake and output, they are usualy ill enough to need hourly observations and may thus be in the critical care unit.
Which of the following should the nursing assistant observe and record when admitting a client?
Answer: 4 Brusing may be due to accidents, abuse, medications, or illnesses, and should be recorded and reported. Freckles and wrinkles are normal skin variations and do not require recording or reporting. Short nails are not problematic; however, long nails may result in the client scratching and injuring herself.
When responding to a client on the intercom, the nursing assistant should say...
Answer: 3 Always give your name and position when answering the call bell, and politely ask the client what she wants. Choices 1 and 2 are incorrect; these questions may come across as the nurse aide acting in a rude manner and should be avoided. Choice 4 is incorrect because it is the nurse aide's responsibility to answer call bells promptly and appropriately.
Which of the following things should the nurse aide do to familiarize new clients with their surroundings?
Answer: 1 The nurse aide should make sure that the client knows how to call for help. Unless otherwise noted, the TV is there for the client to use, and unless otherwise stated, there is no reason to ask the family to leave the room once the client is admitted. Choice 4 is incorrect, because raising the bed to the highest position creates a dangerous situation if the client is left alone.
When arranging a client's room, the nursing assistant should do all of the following EXCEPT...
Answer: 3 Nursing assistants are not allowed to administer medications. The nursing assistant should check to make sure that the call bell is within the client's reach, adjust the back rest as directed, and adjust the room lighting for comfort and visibility.
When assisting a client out of bed, the nurse aide should always...
Answer: 1 Nurse aides should always use proper body mechanics when moving clients. The nurse aide obtains the assistance of another nurse only when it is required. Raising the bed to the maximum height when assisting a client out of bed increases the risk of the client's falling out of the bed and injuring herself. Raised side rails can be used by the client for balance and assist her out of the bed.
How often should clients be repositioned during an eight-hour shift?
Answer: 2 Clients should be turned every two hours to prevent decubiti. Choice 1 is incorrect; unless there is a reason, during a client every hour is too frequent and disruptive to the client's rest. Choice 3 and 4 are incorrect; turning the client every three or four hours is not frequent enough to prevent decubiti.
Which of the following is the correct procedure for serving a meal to a client who must be fed?
Answer: 3 An aide should not bring the tray into the room until he was time to feed the client. Choice 1 is incorrect, because the client may attempt to feed herself and may choke on the food. Choice 2 is incorrect, because it takes time to feed a client and thus the other clients will be waiting too long to recieve their food. Choice 4 is incorrect, because the food will not be palatable after sitting around for an hour.
The most serious problem that wrinkles in the bedclothes can cause is...
Answer: 3 The most serious problems that wrinkles in the bedclothes can cause is decubitus ulcers, also called decubiti. Restlessness and sleeplessness are problematic and may cause health issues, but they are not the most serious problems. Bleeding and shock are not common complications of wrinkled bed clothing.
Restorative care begins...
Answer: 1 Restorative care begins as early as possible to prevent further disability. Choice 2 is incorrect; the planning stage of restorative care can begin before the client is ready. Choice 3 is incorrect; there will not be enough time to successfully carry out restorative care if one waits until discharge. Restorative care is not used for terminal clients/ End of life care may be more appropriate.
Before placing a client in Fowler's position, the nurse aide should...
Answer: 2 Caregivers should always explain procedures first. Turning a client on her abdomen is using the prone position. The Fowler's position requires the nurse aide to raise the head of the bed 45 to 60 degrees. Remaking the bed is unnecessary to place a client in Fowler's position.
During the handwashing, the nurse aide accidently touches the inside of the sink while rinsing the soap off. The next action is to...
Answer: 3 The aide has contaminated her hands and must rewash her hands. She must completely start over. Plain water will not remove bacteria, and the full time required to remove the contamination from the sink.
How should a nurse aide dress for a job interview?
Answer: 3 First impressions are critical, so nurse aides should wear business attire. Choice 1 is incorrect, because the nurse aide should present himself as a well-groomed professional. Choice 2 is incorrect, because wearing a uniform outside of the workplace may be disallowed in some facilities because it can be contaminated. Choice 4 is incorrect, because wearing formal attire is overdressing and not businesslike.
An ambulatory client is newly admitted. Before leaving the client alone, the nurse aide should...
Answer: 4 New clients should always know how to call for help before being left alone. Choice 1 is incorrect; the client may not be allowed to have food due to upcoming testing or surgery. Choice 2 is incorrect; it is the nurse's role to inspect the client's skin at the time of admission. Choice 3 is incorrect; the client was just admitted and thus will not have an intake or output yet.
When lifting a heavy object, the correct method would be to bend at the...
Answer: 3 Keeping the back straight forces the body to use strong leg muscles. Bending at the waist with legs straight can cause back injury, and bending at the waist with rounded shoulders can cause back injury.
When should nurse aides wash their hands?
Answer: 3 Nurse aides should wash their hands after client care to prevent cross-contamination. Nurse aides should wash their hands after eating, after using the bathroom, and after cleaning a bedpan.
When assisting a client with eating, one of the first things the nurse aide should do is...
Answer: 2 Nurse aides must always remember to consider infection control first before anything else. Eventually, food should be cut into 1/3-size bites to prevent choking. Choice 3 is incorrect, because the nurse aide should first ask the client if he wants butter on his bread. Choice 4 is incorrect because the client may want to eat with others to socialize.
A patient has a new cast on her right arm. While caring for her, it is important to first observe for...
Answer: 3 A new cast may cut off circulation, and checking the pulse below the cast helps to make sure that this has not happened. The pulse above the cast willl not help detect cast tightness. A new cast will be damp and should not be touched with fingertips to prevent pitting the cast. Crumbling should not be an issue with a new cast.
Encouraging a client to take part in activities of daily living (ADLs) such as bathing, combing hair, and feeding is...
Answer: 3 Rehabilitation should always be part of the care plan. and encouraging a client to take part in ADLs is an expected role of the nurse aide. This is the nurse aide's responsibility (however, the family can assist the client if they desire to do so and there are no contraindications). Considerate and respectful care is a basic right of all clients.
In caring for a confused elderly man, it is important to remember to...
Answer: 1 The nurse aide should always make sure to follow agency policy. Closing the door causes client isolation, and keeping the room dark and quiet at all times can cause sensory deprivation, which can increase confusion. A confused client needs assistance with bathing and shaving to avoid injury.
Before assisting a client into a wheelchair, the first action would be to check if the...
Answer: 4 Before assisting a patient in a wheelchair, check to see if the wheels of the chair are locked. Making sure the client is covered is important, but not the first action. The nurse should check the floor before entering the room to avoid self-injury, and the door should be open in case the call bell falls out of reach and the nurse aide needs to call for help.
A client has a weak left side. When transferring the client from the bed to the wheelchair, the nurse aide should stand...
Answer: 3 Assist the client at the client's weak side to prevent falls. Choice 1 is incorrect; the nurse aide should stand at the client's weak side, not strong one. Choice 2 is incorrect; this is done for clients who do not have one-sided weakness. Choice 4 is incorrect because the client may slide and fall.
While making rounds at 5:30 a.m., a nurse aide finds a patient lying on the floor. What should the nurse aide do first?
Answer: 4 The nurse aide should assess pulse and breathing first. The client may have fainted. The nurse aide should check pulse and respiration status before calling for help or preforming CPR.
When moving a wheelchair onto an elevator, the nurse aide should stay...
Answer: 1 The nurse aide must stay behind the chair to control it and move it backward to prevent the wheels from falling into the door opening. The nurse aide needs to remain near the client and in control of the wheelchair.
The Foley bag must be kept lower than the client's bladder so that...
Answer: 2 Raising the bag above the bladder level can lead to backflow of urine and can cause bacteria to flow to the bladder. The Foley system is a closed system and should not leak, and the bag can be hidden at almost any height. Preventing backflow doess avoid discomfort, but this is secondary.
As an afternoon snack, the kitchen sent a diabetic client a container of chocolate ice cream. The nurse aide should first...
Answer: 2 The nursing assistant should report this error to the charge nurse, who in turn will contact the kitchen to obtain the correct nourishment. The nurse aide cannot substitute food for a client with diabetes, and diet cola has no calories and is thus not a substitute for a healthy snack. It is the nurse's role to call the kitchen. Choice 4 is incorrect, because ice cream contains sugar and fat, and a diabetic snack needs to be carefully calculated into their overall diet.
When assisting a client who is using the commode, it is important to...
Answer: 1 The client should always have access to a means to help when needed. A locked door slows access to the client in the event of an emergency. Standing next to the client deprives the client of privacy. Restraining a client without an order or consent can be considered unlawful imprisonment.
Ensurinng adequate circulation to tissues is a major factor in preventing skin breakdown. This can be accomplished by doing all of the following EXCEPT...
Answer: 1 The patient must be positioned every two hours to prevent skin breakdown due to poor circulation. Certain mechanical aides are created for the purpose of preventing skin breakdown; backrubs prevent skin breadown by stimulating circulation; and range of motion exercise improves circulation and joint mobility, thus decreasing skin breakdown.
The purpose of cold applications is usually to...
Answer: 3 The purpose of cold applications is usually to prevent and reduce swelling. Warm applications speed the flow of blood to an area. Cold applications are not used to prevent heat exhaustain and will not prevent scar formation.
The hot water bottle is an example of a...
Answer: 1 A hot water bottle applied by itself is local dry heat. A hot water bottle is too small for generalized application.
Clients recieving an enema are usually placed...
Answer: 2 Placing the patient on the left side allows better entry into the colon. Placing a client on the right side or on the back makes entry into the color more difficult. A semisitting position is unstable and causes the client to fall.
A female client's perineal area should be cleansed before which specimen is collected?
Answer: 2 The clean-catch specimen requires cleaning the perinem. A 24-hour urine specimen and a routine urine specimen do not require prior cleaning, regardless of age.
The most common site for counting the pulse is the...
Answer: 4 The carotid artery, femoral artery, and brachial artery are not used routinely to count a client's pulse.
When counting respirations, the nurse aide should...
Answer: 2 Telling the patient that the aide is watching her breathing will cause to patient to slightly changer her breathing pattern. Choice 1 is incorrect, because exercise will temporarily increase the client's respirations. Choice 3 is incorrect because respirations are counted over 30 or 60 seconds. Choice 4 is incorrect because clients cannot count their own respirations.
Which of the following is NOT the nurse aide's responsibility when caring for clients who have urinary catheters?
Answer: 1 Nurse aides are not responsible for catheter insertion. Nurse aides should ensure that the catheter drains properly, take proper precautions to prevent infection, and record the urinary output when a client has a catheter.
When giving information to the charge nurse for an incident report, the nurse aide should...
Answer: 3 An incident report becomes a permanent part of the legal record. Make sure the facts are clear. The nurse, not the aide, documents incident reports. The incident report becomes a hospital record, not a personal record. Incident reports require facts, not opinions.
All long-term nurse aides must be competency evaluated and must complete a distinct educational course. These requirements are set by...
Answer: 1 OBRA' 87 stands for Omnibus Budget Reconciliations Act of 1987. OSHA stands for Occupational Safety and Health Administration. CDC stands for Centers for Disease Control and Prevention. FDA stands for the Food and Drug Administration.
A resident is blind. It is important not to...
Answer: 2 Never rearrange furniture in a blind patient's room after the patient settles into it. This can cause falls. Choice 1 is incorrect; clients who are visually impaired require the same respect and privacy as those who can see clearly. Choice 3 is incorrect; announcing yourself allows the client to know that you have entered the room. Choice 4 is incorrect; explaining the location of food on the plate helps the visually impaired client to be more independent by feeding himself.
When family members visit a client, the visitors should...
Answer: 4 The family members should expect and be allowed private time with their loved one. Visitors should be allowed to visit directly with the client, and as long as possible, wherever appropriate. Family visitation is important to the healing and well-being of the client. Family may help with care if they wish, but should not be require to do so.
A resident asks, "If I need help during the night, who will be there?" The nursing assistant should respond,...
Answer: 4 To make clients feel safe, assure them that help is always there, if needed. Telling a worried client not to worry is not helpful and can be disrespectful. Telling a client to yell for help and saying that a roommate will probably ring the bell is not helpful or reassuring.
Which of the following is a client'r right?
Answer: 1 Clients have the right to confidentiality. This means that all clients have the right to confidentiality, which includes roommates. While clients are allowed to obtain private duty staff, it is not a client right. Clients do not have a right to treat the staff with disrespect.
A resident often cries while she is recieving her p.m. care. What should the nurse aide do?
Answer: 4 It is normal for a person to have moments of sadness, and it is important for the patient to know that the nurse aide cares. The nurse aide should also report this to the nurse in case the crying is the result of something more serious, such as depression. It is inappropriate to tell a client to stop crying, but at the same time, the nurse aide should not ignore clients and their needs. Humor can sometimes help, but will probably not help in cases where sadness seems frequent.
When providing denture care, the nurse aide must...
Answer: 4 Dentures are expensive. The towel prevents breakage if dropped, and the cool water prevents warping. Choice 1 is incorrect; hot wat can damage dentures. Use lukewarm water. Choice 2 is incorrect because holding them under running water runs the risk of dropping and breaking them. Choice 3 is incorrect; dentures need to be carefully cleaned to remove debris and old denture adhesive.
Sexuality in long-term clients may include all of the following EXCEPT...
Answer: 3 As long-term care providers, nursing assistants must respect the resident's right to sexuality. However, engaging in public fondling is inappropriate and may infringe on other resident's rights. Private time with a partner is appropriate for meeting sexual needs, and one's personal appearance and self-esteem are related to their feelings of comfortable sexuality. Desire sexual interaction is a healthy human desire, even in older adults.
A client is scheduled for a partial bed bath. This means that the nurse aide must wash the client's...
Answer: 4 Partiel bed baths are generally given before breakfast due to incontinence to help the client feel comfortalbe and clean. Partial bed baths should include the genital and buttocks area since they are usually given because of incontinence.
A goal for an extended care facility (ECF) resident is that she not swear at the nurses or aides. When she call an aide by his name, the appropriate action is to...
Answer: 1 The nurse aide should positively reinforce the resident's appropriate behavior, so smiling and rewarding her good behavior is the best action. Ignoring positive behavior does not help the patient to continue it, and teasing is not appropriate. The nurse aide should report to the nurse that the client has episodes of not swearing so that the nurse knows that plan is working.
An agitated resident must be turned every two hours all night long. The first action of the nurse aide when waking this resident is to...
Answer: 2 Do not startle the resident, as this may agitate her. The aide should speak quietly as he enters the room. Suddenly turning on the light may startle the resident and increase her agitation, and an agitated client may interpret touch as a threat and lash out at the aide. Shouting can further agitate the client because it may make you appear to be aggressive.
If a client objects to certain food for religious or cultural reasons, the appropriate action would be to...
Answer: 2 Consideration of cultural or religious beliefs is important to all patients. Clients should not be made to wait for their food for any reason, and the dietician should be called that day by the nurse to report the client's religious preferences. Clients should not be forced to do something that is against their religion.
The client's religion forbids eating pork. Bacon is being served for breakfast. The most appropriate response is to...
Answer: 3 The other answer choices do not address the resident's right to practice her religion. Religious preferences need to be considered in client care, even by physicians. Bacon is a pork product and thus inappropriate to serve to this client. Healthy alternatives can be found for dietary needs.
Which type of communication can often be most powerful?
Answer: 3 Listening to someone shows that you are very interested in what he or she is saying.
A client refuses to allow the nurse aide to bathe her. The nurse aide tells the client that she will not be allowed to eat lunch to go to bingo if she does not have her bath. This is an example of...
Answer: 3 Threatening to withhold activities and food is verbally abusive. Choice 1 is incorrect because this is an inappropriate restriction that can hinder rehabilitation. Choice 2 is incorrect because threats are not discipline. Choice 4 is incorrect because this is abusive behavior; however, there is no physical contact, thus this is not physical abuse.
One entering a room, an aide notices that the client is not breathing. The aide's first action should be to...
Answer: 1 Always call for help first in an emergency. The aide should call for help first, before he takes any physical action. Abdominal thrusts are not used until the rescuer verifies that the client's airway is blocked.
A client's dentures are lost. The first action should be to...
Answer: 4 The first step for any lost belongings is always to notify the charge nurse. The nurse should report their loss before looking for them. The nurse aide does not report directly to the administrator or to the physician.
Nursing assistants are responsible for...
Answer: 2 Nursing assistants work under the supervision of practical and registered nurses and perform tasks assigned to them. Choice 1 is incorrect; nurse aides can participate in planning client care, but they are not responsible for it. Choice 3 is incorrect; personnel should ask for help when needed, including nurse aides. Choice 4 is incorrect; nurse aides should focus on their own assignments and not be concerned about the assignments of others.
A patient turns on the call light when he needs to urinate. The appropriate action is to...
Answer: 3 A nurse aide should answer any call light as soon as possible. Choice 1 is incorrect; nurse aides are responsible to answer call lights for all clients, when in a position to do so. Choice 2 is incorrect; clients should not be made to feel that they need to wait in line for care; the nurse aide should answer the call light as soon as possible to assure that there is not an emergency.
A client is on CMR and in the prone position. The nurse aide finds the client vomitting bright red blood. The nurse aide should first...
Answer: 2 Placing the client in a side-lying position prevents aspiration of the vomitus. Choice 1 is incorrect; while the nurse aide does need to clean the client, this is not the priority. Choice 3 is incorrect; the client is lying down and thus cannot use an emesis basin. Choice 4 is incorrect; the nurse aide should call the charge nurse after he places the client on her side.
When performing catheter care, the nurse aide should wash the catheter...
Answer: 3 You should follow the clean-to-dirty priniciple, which the meatus considered cleaner than the catheter tubing. Choice 1 is incorrect; washing towards the meatus drags bacteria up the catheter into the meatus, possibly causing infection. Choice 2 in incorrect; soap and water should be used in catheter care. Choice 4 is incorrect; alcohol can cause irritation of the urinary mucosa.
A nurse aide who applies restraints on a client without directions from the charge nurse may be accused of...
Answer: 3 Applying restraints without an order or without consent can be considered false imprisonment. Choice 1 is incorrect because slander is transient, usually verbal, defamation of character. Choice 2 is incorrect because battery is unlawful physical contact. Choice 4 is incorrect because negligence is failure to exercise reasonable care.
H.S. care is care that is given...
Answer: B H.S. is the medical abbreviation for hours of sleep. Choice 1 is incorrect; the medical abbreviation for before meals is a.c. Choice 3 is incorrect; the medical abbreviation for after meals is p.c. Choice 4 is incorrect; while not commonly used, o.m. means on morning.
The best foods for a geriatric client with no teeth would include...
Answer: 4 Of the choices listed, only choice 4 contains a soft diet. Choices 1, 2, and 3 all contain foods difficult to eat without teeth.
A client's family wants to talk about the client's impending death, but the client does not want to talk about it. The family should be encouraged to...
Answer: 1 If the client does not want to talk about death, the family should be allowed to talk privately, away from the client. Choices 2 and 4 are incorrect because the client's wishes should be respected and clients should not be forced to talk about something they do not want to talk about. Choice 3 is incorrect; the family should be able to verbalize their feelings now and not have to wait.
When should postmortem care be performed?
Answer: 2 Postmortem care needs to be done before rigor mortis sets in so that the patient's appearance can be maintained. Once rigor mortis sets in, the body will be difficult to position. Postmortem care should occur before the family comes to view the body to remove any bodily fluids and treatment remnants. In some facilities, the funeral director completes postmortem care; however it is initiated on the medical unit.
A walker may be used if the client can...
Answer: 1 A resident must be able to support some weight before using a walker. Hand strength alone is not adequate for walker usage, and though balance is important, the patient must first be able to support some weight. If the person can walk independently, she does not need a walker.
A cane should be used on...
Answer: 2 If the cane is not used on the strong side, the resident may fall. Switching sides will not strengthen the weak side, and the client may fall when the cane is used on the weak side. Choice 3 is incorrect because though arm strength is important, it is not as important as leg strength.
A nurse aide is collecting linens for a bed change and drops a sheet on the floor. What should the nurse aide do?
Answer: 3 To prevent contamination and spread of microorganisms, the sheet should be put in the soiled linen hamper. Linens acts a fomites, and this linen has been contaminated and cannot be used until it is washed. Leaving bed linens on the floor creates a fall hazard.
When applying a cold treatment to a patient, it is important to observe the patient closely for signs of...
Answer: 4 Cyanosis is an indication of poor circulation, which could lead to tissue death. The nurse aide should stop the treatment and report it to the charge nurse. Redness would be an issue with hot treatment, not with cold treatment. Cold packs should not result in dizziness or fainting.
The purpose of correctly positioning the client is to...
Answer: 4 Correctly positioning a patient should prevent skin break- down, increase comfort, and maintain the function of the joints and muscles.
A surgical bed should be left in what position?
Answer: 4 The bed should be level with the stretcher. This makes the transfer safe. Choice 1 is incorrect; in Fowler's position, the head of the bed is raised between 45 and 60 degrees, making transfer from the stretcher difficult and unsafe. Choice 2 is incorrect; the lowest position will not be level with the stretcher, making transfer unsafe. Choice 3 is incorrect; in semi-Fowler's position, the head of the bed is raised between 30 and 45 degrees, making transfer from the stretcher difficult and unsafe.
The preferred way to remove a bedpan from a client who is unable to lift her buttocks is to...
Answer: 3 Turning the resident is the easiest method, it is important to hold the pan to prevent spilling the contents. Choice 1 is incorrect; mechanical lifts are used for people who are very heavy or who are unable to assist in transfer. Choice 2 is incorrect; having another aide assist in lifting the patient is a possible way, but not the preferred way since that help may not be available when needed and you do not want the client to sit on the bedpan any longer when necessary. Choice 4 is incorrect; slowly siding the pan from under the client risks the possibility of spilling the contents onto the bed.
After shaving a patient with a safety razor, the nurse aide should...
Answer: 3 Sharps containers are puncture resistant. They are used to prevent contact with bloodborne pathogens. Sharps should never be tossed into the trash. They may cause injury, and there is concern of serious infection. Safety razors are for one-time use.
When a client complains that his dentures are hurting, the appropriate action is to...
Answer: 2 Always bring such complaints to the charge nurse. Choice 1 is incorrect; poorly fitting dentures are painful and can cause injury to the mouth. Choice 3 is incorrect; the nurse aide reports directly to the nurse; not the physician. Choice 4 is incorrect; dentures are kept safely in a denture cup, labled with the client's name. Leaving them on the table risks both contamination and damage.
A nurse aide notices that a water pitcher has spilled onto the floor. The best action for the aide to perform is to...
Answer: 1 Take care of spills immediately, or a patient may be injured while waiting for housekeeping. It is not necessary to notify the charge nurse for this, and leaving the spill to find the charge nurse or housekeeping increases the chance of someone falling on it. Covering it with a towel could create a fall hazard.
Upon entering a room, the nurse aide notices that a patient is not breathing. The aide's first action is to...
Answer: 1 Call for help to activate the facility's emergency medical services. Early activation increases the client's chances for survival. Choice 2 is a correct action, but not the first action. Choices 3 and 4 are incorrect; check the airway before giving rescue breaths and do not start thrusts until you verify the person's airway is obstructed.
A patient is on bed rest, wearing anti-embolitic stockings. How often should the stockings be removed?
Answer: 3 To allow normal blood flow to the lower extremities, the stockings should be removed twice a day. Anti-embolism stockings are removed every 8 to 12 hours to allow for adequate circulation. They prevent blood from pooling in the lower extremeties, and therefore should not be removed too often.
Pressure ulcers (decubitus ulcers) can be prevented by...
Answer: 4 Chaning positions frequently and using a gel or foam pad are both key. There is no data to suggest that vitamin C prevents pressure ulcers.
The first step in getting a client up to walk is to...
Answer: 3 Always make sure the resident is allowed to get up first. The nurse does sit the client on the side of the bed before standing, put the client's slippers on before standing, and tell the client that he will be getting up, but not before checking the activity order.
A client's vital signs are as follows: 118/80-98.8-80-30. Which finding should be reported at once?
Answer: 4 The respiratory rate of the client is elevated. The blood pressure, temperature, and pulse are within normal limits.
All of the following can cause an inaccurate oral temperature reading EXCEPT...
Answer: 2 Electronic thermometers are commonly used for assessing temperature. Drinking hot liquids, failing to shake down a glass thermometer, and exercising vigoroysly prior to an oral temperature reading cause an inaccurate reading.
Diastolic blood pressure is determined by...
Answer: 2 The diastolic blood pressure occurs when the heart muscle relaxes. It is the bottom number of the reading and is the last sound heard before silence. The systolic blood pressure occurs when the heart muscle contracts, and the difference between the systolic and diastolic pressure is the pulse pressure. There is no reason to add the systolic and diastolic pressures.
All of the following are correct when measuring blood pressure, EXCEPT...
Answer: 3 Always use a cuff that fits. If the cuff is too large, you will get a reading that is too low. Choice 1 is incorrect; inflating the cuff may cause pain at the IV site and may cause the IV catheter to dislodge. Choice 2 is incorrect; some people who have mastectomies also have axillary (armpit) lymph nodes removed, which disrupts fluid flow in the arm and can lead to inaccurate blood pressure reading. Choice 4 is incorrect; blood pressure may be difficult to hear, and thus the room should be quiet.
The first step in performing any procedure is to...
Answer: 3 Infection control (handwashing) is always the first step in a procedure. Explaining the procedure is important and assuring privacy is important, but you should wash your hands before approaching the client. Wash your hands before touching equipment to avoid contamination.
Which of the following best destroys all bacteria?
Answer: 3 Sterilization is the most thorough method of destroying bacteria. Antiseptics, such as alcohol, are used to prevent pathogens from spreading and may kill them. Disinfectants, such as bleach, can kill bacteria, but are too stand to use on the skin. Sanitation, including scrubbing in hot water, removes pathogens to prevent them from spreading.
In the event of a fire in a client's room, the nurse aide should first...
Answer: 3 Always get the client to safety first. Do not use time to notify the nurse. Turn on the alarm after getting the client to safety. You can use the fire extinguisher in the event of a small fire, but do so after getting the client to safety.
Safe use of oxygen therapy includes...
Answer: 4 Smoking in bed brings all three elements of a fire together: linens for fuel, heat from the cigarette, and oxygen from the air. Choice 1 is incorrect, because the flow is determined by the physician. Choice 2 is incorrect, because wool can cause sparks. Choice 3 is incorrect, because alcohol causes drying.
During CPR, the client should be lying...
Answer: 1 The client should be lying flat on a hard surface to assure adequate compression and blood flow. The head and shoulders should be level with the rest of the body, and the feet should be level with the rest of the body. A bed mattress is too soft for effective chest compressions.
A procedure manual is a...
Answer: 1 A procedure manual is a written set of instructions on how to perform procedures. A job description contains the general tasks, or function, and responsibilities of that position. The procedure of administering medications would probably be found in the procedure manual, but the procedure manual would contain other procedures. The nurse aide assignments will most likely be created by the charge nurse.
If a client cannot speak English, the nures aide should...
Answer: 2 It is mandatory to provide a certified interpreter to clients not fluent in English. Choice 1 is incorrect; using a family member to interpret sacrifices confidentiality. Choice 3 is incorrect; this is not appropriate for either translation or the nurse aide role. Choice 4 is incorrect; clients have a right to have their questions answered as quickly as possible.
The accepted way to identify a client is to...
Answer: 2 An identification band is the only definitive way to identify the patient. A confused patient may answer to any name or may not know his name. A confused client may also be in the wrong bed.
Which of the following best describes nail care?
Answer: 3 All residents need nail care, and nail care is part of the nurse aide role. The nursing assistant should be able to obtain information needed from the care plan. Nails are cut with nail clippers.
When performing perineal care on a male client, always...
Answer: 2 Material may build up under the foreskin in uncircumcised males unless the foreskin is retracted for cleaning. Choices 1, c, and d are incorrect. You should wash the penis before the scrotum, move from the tip of the penis to the base, and hold the penis slightly away from the body.
Back rubs aid in all of the following EXCEPT...
Answer: 1 Back rubs are not used to improve posture. They improve circulation, give the nurse aide some time to talk to the client, and help to relax the client.
A client's elbows are dry and red. The nurse aide should...
Answer: 1 Report this to the charge nurse, since there are many reasons for redness. The redness and dryness may not be due to dry skin or friction rubbing. Range of motion may cause additional problems, depending on the cause of redness and dryness.
A decubitus ulcer can be caused by all of the following EXCEPT...
Answer: 4 Poor circulation, poor nutrition, and pressure on the skin all can cause decibitus ulcer. Poor circulation is a risk factor for pressure ulcers because the skin is deprived of nutrients and oxygen. Poor nutrition is a risk factor for pressure ulcers. Pressure deprives the skin of blood flow and thus nutrients and oxygen, causing cells to die.
The nursing assistant shampoos a client's hair to improve all of the following EXCEPT...
Answer: 4 Shampooing can improve circulation to the client's scalp, the client's appearance, and the client's sense of well-being, but not hair growth rate.
When removing a soiled gown from a client who has an IV, the best action is to...
Answer: 1 Remove the sleeve from the arm without tubing first. The IV catheter is not removed for clothing changes, and the IV is not disconnected by the nurse aide.
If a client does not eat all the food on his tray, the first thing an aide should do is...
Answer: 2 The patient may not be eating due to personal dislike of the food. Asking first allows the nurse aide to request a replacement if the problem is simple. Notifying the charge nurse is not the first thing the nurse aide should do. You should remove the tray after trying to find out why the client will not eat. The client may simply need more seasoning. Do not force clients to eat.
The client states that a mistake was made: There is salt on her tray, although the doctor has ordered a low-salt diet. The nurse aide shoud...
Answer: 3 Any diet question must be answered before the resident eats. The nurse aide should not conduct dietary teaching, and should always check the diet order with the nurse first.
Which of the following provides identification of clients in long-term care facilities?
Answer: 3 Both identification bracelets and photographys are used for identification purposes in long-term facilities. Confused clients may not know their own names.
Before transferring a client from the bed to a wheelchair, the nurse aide should sit her on the edge of the bed for a few minutes to...
Answer: 2 Orthostatic hypotension is the light-headed feeling we all get when we rise too quickly. The gown or clothing is rearranged once the client is in the wheelchair, and the wheelchair should be positioned and secured before moving the client. The transfer belt is not removed before moving the client.
The client's religion forbids eating meat. Beef stew is being served for lunch. The nurse aide should...
Answer: 3 The other answers doe not address the resident's right to practice religion or her right to choice. Religious restrictions are to be respected by healthcare providers.
It is important to remember that dying patients...
Answer: 1 Not all dying patients have the same problems, but they have all the same care needs as anyone else. Choice 2 is incorrect; many dying patients want companionship in their final hours. Choice 3 is incorrect; dying patients should be consulted regarding their care needs. Choice 4 is incorrect; not all dying patients are in pain.
Dying patients and their families...
Answer: 3 Because each dying resident has unique emotional needs, each person will go through the stages at different times and in a different order. We now know that people experience loss differently and that they may not experience all the stages, nor may they experience them in order. Many people do not accept death before it occurs.
Which of the following is an early sign of dementia in an elderly client?
Answer: 2 Memory loss is a sign of dementia. Refusal to eat is not a sign of dementia, but difficulty cooking a meal is an ealy sign. Headaches and frequent urination are not signs of dementia.
Clients with Alzheimer's disease may have all of the following characterisitics EXCEPT...
Answer: 1 Clients with Alzheimer's disease should not have signs of physical wasting away, unless they have not been cared for. This may be a sign of neglect. Memory loss, wandering, and irrability are characteristics of Alzheimer's disease.
When a client turns on the call light every few minutes, the appropriate response is to...
Answer: 2 Patients who use their call bell frequently are usually afraid they will be ignored if they don't often call. Stopping in frequently reassures them. The client should always have access to the call bell. Asking the client to no call so often is inappropriate, and telling the client the staff is busy can increase her fear that her needs will not be met.
The doctor writes an order for "do not resuscitate" (DNR). What does this mean?
Answer: 3 "Do not resuscitate" means that no attempts will be made to resusciate the patient. Ventilators will not be used if there is a DNR order and the patient will not be kept alive artificially. CPR should not be initiated.
How a client reacts to illness and disability is most dependent on his...
Answer: 4 A person's total environment always affects everything that person does and thinks. Age and stage of life do affect a client's reactions, but they are not the most critical factors. A patient's overall support system plays a stronger role than just the spouse's support. Income and level of education do affect a client's reactions, but they are not the most critical factors.
A client with dementia makes sexual advances towards another client who has dementia. The nurse aide should...
Answer: 4 Clients with demential are not able to give consent; therefore, the nurse aide has a responsibility to protect clients from sexual advances. Choice 1 is incorrect; while OBRA'87 does state that clients must be allowed to fulfill their sexual needs, clients with dementia cannot legally consent to sexual activity. Choices 2 and 3 are incorrect; this is inappropriate sexual activity because clients with dementia cannot legally consent to sexual activity.
A client hits a nurse aide during lunch. The appropriate response is to...
Answer: 1 Obtaining assistance is the only correct way to deal with abuse by a resident. This is abusive behavior, and it should not be ignored. Choice 3 is incorrect, because restraints require physicians's orders. Choice 4 is incorrect; yelling at patients is also abusive.
A resident is confined to her bed. What might keep her from getting pressure sores?
Answer: 4 An air mattress relieves pressure. Air pressure alteration reduces pressure against the body to prevent circulation impairment. Choice 1 is incorrect; a plastic dray sheet can irritate delicate skin by holding moisture against the skin. Choice 2 is incorrect; a foot board is helpful, but alone will not prevent pressure sores. Choice 3 is incorrect; lotion and massage are helpful, but will not prevent pressure sores alone.
If the client is in traction, the nurse aide should never...
Answer: 3 Position of weights in traction is ordered by the physician. Therefore, the nursing assistant should never change the position of the weights without an order. The skin temperature should be monitored because coolness can indicate decreased circulation. Total bed baths are not contraindicated because of traction. Distal pulses should be monitored in clients with traction to check for adequate circulation.
Security for a client's dentures includes...
Answer: 2 Every resident with dentures must have a labeled denture cup to ensure security of costly dentures. Residents should not be forced to wear their dentures, and markers and pens should not be used on dentures.
If family members bring new clothes in for an ECF resident, the nurse aide should...
Answer: 2 All residents have the right to their own personal possessions. Labels allow the aide to better provide protection. Choice 1 is incorrect; the nurse aide should label the clothing before placing them in the resident's dresser. Choice 3 is incorrect; the resident is entitled to keep her personal possessions. Choice 4 is incorrect; the nurse aide can label and store clothing without consulting the nurse.
The charge nurse intructs the nurse aide to clean an ECF resident's closet. The nurse aide should...
Answer: 3 The client has a legal right to decide what to keep and what to throw away, but may need assistance in the cleaning process. The family is not required to clean the resident's closets, and the nurse aide should not pass off her responsibilties to another nurse aide. ECF clients are not usually well enough to clean their closets, nor should they be expected to clean them.
Before dressing an ECF resident, the nurse aide should...
Answer: 3 A nurse aide should always close the door to promote privacy. Except for unusual circumstances, there are no orders for how a client should be dressed, and dressing does not require reporting to the charge nurse. The client has the right to choose her own clothing.
Confidentiality refers to...
Answer: 2 Confidentially refers to the client's right to privacy. Choice 1 is incorrect; client information is shared with the rest of the healhcare team of the client's hospital or ECF unit. Choice 3 is incorrect; chart documentation is important to promote communication and to provide a lasing document of the client's hospitalization or ECF stay. Choice 3 is incorrect; clients do not have a right to insurance.
During A.M. care, the nurse aide nicks a resident while shaving him. What should she do first?
Answer: 3 The first step is to stop bleeding in order to ensure the patient's comfort. Choice 1 is incorrect; the nurse aide should report this to the charge nurse, but it is not the priority. Choice 2 is incorrect; doing nothing can cause excessive bleeding in clients who have bleeding tendencies, such as those who are taking anti-clotting medications, and may also lead to infection. Choice 4 is incorrect; bleeding should be stopped first.
Maintaining good interpersonal relationships depends on...
Answer: 2 Clear communication is critical to good interpersonal relationships, while contact avoidance can damage them, One can disagree and still maintain good interpersonal relationships. Following orders without questioning can lead to resentment and doing things improperly if the orders are not correct.
If a nursing assistant does not know how to complete an assignment, he should...
Answer: 3 Asking for help from a supervisor is a critical component to career growth. Choice 1 is incorrect; the other nursing assistant may also not know how to complete the assignment. Choice 2 is incorrect; nurse aides should not ask clients for assistance with understanding assignments. Choice 4 is incorrect; policy manuals contain policies, not assignment procedures.
Reporting what the client tells you is an example of...
Answer: 1 Subjective observation comes from what the client tells you. Objective observation comes from what you see, hear, feel, or smell. Primary observation relates to what should be considered first. Secondary observation relates to what is considered after primary observation.
Incontinence means that the patient is...
Answer: 4 Incontinence is generally due to a medical problem. It is important to adhere to a bowel/bladder training program. Aboulia is the term for the inability to make decisions. Aphasic is the term for the inability to speak. Gero and geri are used in terms that relate to aging.
Failure to raise the side rails on the bed of a confused client is an act of...
Answer: B Negligence is an unintentional act of injury. It is breech of civil law, not criminal law. Malpractice is negligent treatment of a patient by a professional. Overt commission means openly acting on something, such as deliberately injuring a patient.
During a job interview, it is important to tell the interviewer about...
Answer: 1 You need to sell yourself during the interview. Ask about benefits and your personal needs after you get the job. Do not discuss scheduling problems until after you have been offered the position, and do not discuss salary expectations until after you have been offered the position or at least until the interviewer has discussed it with you.
When a nurse aide cannot work due to illness, the nurse aide should...
Answer: B Contact a supervisor as soon as possible, so that a replacement can be found in a timely manner. Choice 1 is incorrect; the nurse aide is not responsible to cover his or her shift. Choice 3 is incorrect; calling one hour before the shift begins decreases the change that someone else can be found to cover it. Choice 4 is incorrect; waiting for the charge nurse to call you is not responsible behavior and may result in disciplinary action.
What is the main goal of OBRA'87?
Answer: 3 All healthcare providers must be responsible for their actions. OBRA'87 does not cover hospice facilities, oversee payment of care costs, or act to shorten hospital stays.
The client asks to see a priest. The nurse aide shoud...
Answer: 1 It is the client's right to have clergy available as requested. The client should not have to rely on chance to see a clergy person, nor should she have to contact the clergy person herself. It is not the physician's duty to call the priest in this case.
When caring for a client who has just been placed on NPO, the nurse aide should first...
Answer: 3 NPO means nothing by mouth, so removing all food and water will reduce temptations. Encouraging someone not to think about something typically results in her thinking about it. The client had just been placed on NPO and thus mouth care is not required at this time.
If a nurse aide sees another employee hit a client, the nurse aide should...
Answer: 4 Tell the charge nurse immediately when you suspect abuse. You are legally obligated to report it, and you want to do so as soon as possible to prevent further abuse. The nurse aide should not directly confront an abusive employee, nor should she wait to see if it will happen agian, as that can result in another client being injured. Answer 3 is also incorrect; another nurse aide cannot do anything to help, so you should tell the charge nurse.
Which statement about mouth care for unconscious residents is correct?
Answer: 1 The last sense to leave is hearing; speak with kindness and be aware of what you say. Unconscious residents cannot swallow and spit, which means mouth care must be carried out carefully to prevent aspiration. The mouth and lips of an unconscious patient can easily become dry and sore, thus they need frequent mouth care and observation for sores.
A hearing-impaired client has the right to all of the following EXCEPT...
Answer: 4 The client has the right to assistance with hearing aids, but there is no right that pertains to getting expensive options. A hearing imparied client may need written notes to understand procedures and directions or an interpreter, especially if the client uses sign language.
When documenting a client's vital signs, the nurse aide makes a mistake. The nurse aide should...
Answer: 3 Charting errors are corrected by using a single black line through the error, marking it with the word "error," and initialing it. The client's chart is a legal document, and covering the error with a heavy black marker or correction fluid is unacceptable.
Inactivity and immobility may cause all of the following EXCEPT...
Answer: 3 Intestinal peristalsis decreases with inactivity and immobility. Pressure ulcers are the most common complication of immobility. Contractures occurs when a joint is left in the same position for a long time, and decreased fillings of the lungs from immobility allows fluid and mucous to build up in the lungs.
The nurse aide know that the term "up ad lib" means the client...
Answer: 2 "Up ad lib" is an activity order suggesting the client can perform ADLs independently with periods of rest as needed. "Completel bed rest (CBR)" means that the client is not permitted out of bed. Clients allowed out of bed for mealtime only usually have an order that specifies this. "Ambulate with assistance" is the term usually used for clients who need assistance with activities.
When lifting a patient, it is important to use good body mechanics. The nurse aide should...
Answer: 2 It is important to use the large muscles in the legs and thighs to prevent back injury. Keeping the patient at arm's length risks the patient falling and the nurse aide hurting his back, and twisting at the waist can cause back strain. Moving the patient rapidly can causes injury to both the patient and the nurse aide.
A common sign of approaching death is...
Answer: 4 As circulation slows, body functions decrease. Appetite and vital signs decrease when death approaches. Not all dying patients are in severe, unceasing pain.
Tuberculosis is a disease of the...
Answer: 3 Tuberculosis most commonly affects the lungs. A person with tuberculosis in the lungs can spread it to others through droplets in respiratory secretions. Tuberculosis does not usually affect the throat or colon. While it may spread to the kidneys, it is primarily a lung disorder.
The nursing assistant notes that a client's respiratory rate is zero. The nursing assistant should...
Answer: 4 Respiratory rate of zero may signal approaching death; contact the nurse immediately. Choice 1 is incorrect; a respiratory rate of zero means that the client is not breathing, and this should be reported immediately. Choice 2 is incorrect; the client will die if there is no immediate intervention- ten minutes is too long to wait. Choice 3 is incorrect; it is not the nurse aide's responsibility to notify the family when there is a death.
After a client dies, the client's spouse wishes to share his emotions. The nurse aide should...
Answer: 1 Caring for the family is part of the job, and thus the nurse aide should comfort the spouse. Nurse aides do not need to call the charge nurse; they can use their therapeutic communication skills to communicate with family and relatives of dying clients. If the client wants to share his emotions, the nurse aide should be a good listener and not change the subject.
An example of a special device to help prevent contractures is a(n):
Answer: 1 A handroll is placed in the palm of the hand to prevent the hands and fingers from contracting into a flexed position. A doppler is a type of measuring device, such as an ultrasound or blood pressure device. An air mattress is used to prevent pressure ulcers. A manometer is an instrument used of measuring the pressure of gases and vapors.
Falsely stating that a coworker took a client's money is an example of...
Answer: 3 Defamation is harming a person's reputation by words that you say (slander) or write (libel). Negligence is a failure to exercise reasonable care; it is an unintentional wrong. Assault is threatening a person or attempting to touch a person without their consent. Hoarding is the accumulation of food and other items.
Hemiplegia refers to...
Answer: 1 Hemiplegia refers to paralysis of one side of the body. Paraplegia refers to paralysis of the legs or lower body. Cruciate paralysis is paralysis of an upper extremity. Quadriplegia refers to paralysis of all four extremities.
The most accurate method of measure body temperature is...
Answer: 1 The rectal temperature method is considered the most accurate, as the thermometer is in direct contact with membranes. An oral temperature reading can be affected by many factors, including the client's drinking hot or cold fluids just before the readings. The axillary temperature can be affected if the patient just washer under her arms or applied deodorant. Feeling the forehead is an inaccurate way to measure temperature; however, there are temporal thermometers that are swept across the head to measure temperature.
Which of the following sets of vital signs should be reported immediately?
Answer: 2 A temperature of 102.4oF is elevated. The patient's pulse indicates tachycardia, which is a fast pulse, and the patient's blood pressure is high, indicating hypertension. Choice 1 is incorrect; these vital signs are within the normal limits. Choice 3 is incorrect; the temperature is at the high end of normal, as is the systolic blood pressure. These do need to be reported, but not immediately. Choice 4 is inccorect; these vital signs are within normal limits.
A client consumed 180 cc of tea, 60 cc of soup, and 120 cc of ice cream. What is her total fluid intake?
Answer: 3 Ice cream is a fluid, so the client's total intake is 360 cc. Fluid intake is as follows: 180 cc (tea) plus 60 cc (soup) plus 120 cc (ice cream) equals 360 cc. Choices 1, 2, and 4 are incorrect because the numbers do not add up to 360 cc.
A client is placed on a strict I&O after surgery. The nurse aide should...
Answer: 4 I&O refers to fluid intake and urinary output, as well as other outputs, including drainage. Choice 1 is incorrect; the nurse aide cannot place a client on NPO without an order. Choice 2 is incorrect; soild food intake is not included in the I&O. Choice 3 is incorrect; this is only partially correct since fluids are output would be measured.
Which of the following would be included in a client's output record?
Answer: 2 Urine, emesis, and bleeding are all considered output. Choice 1 is incorrect; food eaten is not included in I&O and IV solutions are included in the intake. Choice 3 is incorrect; liquids are part of intake. Choice 4 is incorrect; bowel movements are included if liquid, but not the only inclusion in output.
Which of the following is an intake-and-output problem that the nurse aide must report?
Answer: 3 Failure to void (urinate) may indicate kidney failure. The normal adult urinary output is 1,500 cc per day, or approximately 500 cc per eight-hour shift. While a client's stating he is not hungry is important to note, this is not an I&O problem. A client's request for a bedpan is not typically reported.
A client's water pitcher holds 500 cc. The pitcher is full at the beginning of the shift, and empty halfway through the shift. The nurse refills it, and the client drinks half of the pitcher by the end of the shift. The total water intake for this client at the end of the shift is...
Answer: 3 A full pitcher at 500 cc, plus a half pitch, plus a half pitcher at 250 cc equal 750 cc of water. 250 cc would be one half of the water pitcher. 500 cc would be a full water pitcher. 1,000 cc would be two full water pitchers.
The nurse aide finds a damaged piece of equipment. The nurse aide should...
Answer: 3 Immediately reporting equipment damage can prevent an accident. It is not the nurse aide's role to repair equipment. Most equipment is costly and repairable, and thus should not be thrown away unless the nurse aide is told to so so. Using faulty equipment is hazardous and can result in injury.
After caring for a confused client, the nurse aide fails to pull up the safety rails, and the client falls out of the bed and fractures a hip. This is called...
Answer: 2 Negligence is an unintentional wrong. Abuse is an intentional act that causes harm to another person. Battery is the infliction of injury. Assault is threatening a person or attempting to touch a person without his consent.
A nursing assistant is giving foot care to a resident. What should he NOT do?
Answer: 1 Only a podiatrist or a nurse can remove corns. Choice 2 is incorrect; soaking the feet may help to soften corns. Choice 3 is incorrect; the nurse aide should check the skin for signs of breakdown when performing foot care. Choice 4 is incorrect; an orangewood stick is used to clean underneath a person's toes.
When restraints are in use, the nurse aide should report all of the following EXCEPT?
Answer: 4 The aide's experience is not part of the client's record. There are different types of restraints, and thus the nurse aide should document the type used for the client. Restraints are removed every two hours to allow for repositioning, and can sometimes cause bruising and other complications. Both pieces of information should be recorded.
The pulse located in the neck is called the...
Answer: 4 The carotid pulse is located in the neck. The apical pulse is located on the chest, over the apex of the heart. The femoral pulse is located in the groin area. The radial pulse is located on the inside of the wrist.
A client complains of numbness on one side of the body. The client's grip is weak and speech is slurred. The nurse aide should...
Answer: 4 These are all signs of a possible CVA (stroke), and the nurse aide should report this to the charge nurse immediately to prevent further damage to the client. Choice 1 is incorrect; the client may be having a CVA, but is not the nurse aide's role to call the physician. Choice 2 is incorrect; a CVA needs immediate medical attention, thus the nurse aide should not waste time taking the client's blood pressure. Choice 3 is incorrect; a CVA requires immediate attention, and thus the nurse aide needs to report these signs immediately.
When providing perineal care to a female patient, it is important to wash from the front to the back to avoid spreading bacteria found in the resident's...
Answer: 4 Bacteria from the rectum can cause urinary tract infections. The pancreas is an internal organ located in the abdomen. Poper perineal care is used to prevent contaminating the vulvus or meatus with bacteria.
The order "vital signs q.i.d." means to record vital signs...
Answer: 1 Q.i.d. means four times a day. B.i.d. means twice a day. Q.a.m. and q.p.m. mean every morning and evening. Qshift means once per shift.
The nurse aide notices that a client has an open red area on her coccyn that is draining. The nurse aide should...
Answer: 4 An opening in the skin prediposes the client to infection and must be checked by the nurse. The nurse aide should not touch the area before telling the nurse, and alcohol would cause pain on an open wound. The wound may get worse if the nurse aide waits another day.
A nursing assistant is ambulating a client in the hallway. Suddenly, the client complains of chest pain and shortness of breath. The nurse aide should first...
Answer: 3 Do not leave the client in an emergency. Chest pain and dizziness may signal a myocardial infarction (heart attack). Choice 1 is incorrect; the client may be having a heart attack (myocardial infarction) and should not continue to ambulate. The nurse aide should not leave the client, so all other choices are incorrect.
A client finishes drinking a glass of cold water just as the nurse aide arrives to take the client's rectal temperature. The nurse aide should...
Answer: 4 Take the client's rectal temperature as planned, because the cool water would affect the oral, not rectal reading. Choice 1 is incorrect, because waiting 15 minutes after a client drinks cold water is for oral temperatures. Choice 2 is not necessary, since the nurse aide is taking a rectal temperature. Choice 3 is incorrect; there is no need to report this to the charge nurse.
Which of the following observations should be reported immediately?
Answer: 3 Bluish discoloration (cyanosis) indicates low oxygen level in the body. The condition can be life threatening. T-98.2, P-88, R-20 are normal vital signs. Yellow is a normal color for urine. The skin should be warm and dry to the touch.
Microorganisms can be spread by direct and indirect contact. An example of indirect contact is...
Answer: 3 Objects such as bed linens, dishes, and dirty instruments harbor microorganisms. Bathing a patient, using contaminated blood, and breathing dust particles are all examples of direct contact.
Which statement about handwashing is correct?
Answer: 2 Hands should be washed at least two inches above the wrist. Choice 1 is incorrect; the faucet is most likely contaminated by dirty hands. Choice 3 is incorrect; hands should be washed in warm water. Choice 4 is incorrect; according to the CDC, hand sanitizers can be used for routine hand decontamination.
The nursing assistant finds a client lying on the floor. The nursing assistant should first...
Answer: 3 Shaking and shouting helps determine if the client is conscious and oriented. Choice 1 is incorrect; the nurse aide should not leave the client. Choice 2 is incorrect; the client may be unconscious or not breathing. Choice 3 is incorrect; the nurse aide should first check the client, and then summon help. Calling 911 is not typical in an inpatient facility.
Which statement about use of fire extinguishers is correct?
Answer: 2 Different extinguishers are used on various types of fires. Choice 1 is incorrect; fires are classified as A (fueled by ordinary material), B (fueled by a petroleum product), or C (an electrical fire), and only ABC fire extinguishers can be used for all three. Choice 3 is incorrect; nurse aides are responsible for using fire extinguishers correctly. Choice 4 is incorrect; fire extinguishers are used for fires of all sizes.
A client begins to choke during feeding. The client is conscious but unable to speak or cough. The nurse aide should...
Answer: 3 Abdominal thrusts can dislodge the obstruction. Choice 1 is incorrect; the nurse aide witnessed the client choke during feeding and noted the client is unable to speak; therefore, the nurse aide knows the client is not okay and cannot respond to her. Choice 2 is incorrect; it is not the nurse aide's role to call a physician. Choice 4 is incorrect; sweeping the mouth may push the oject further into the airway.
The nurse aide should tell the licensed nurse of a patient with _________ does not finish the food on his tray.
Answer: 3 A diabetic's blood sugar is contolled by diet and medication. Any food not eaten will affect the blood sugar level. Missing part of one meal should not create problems for the client in situations 1, 2, or 4. However, this should be reported at the end of the shift.
Which of the following tasks is NOT within the job description of the nurse aide?
Answer: 3 Only a licensed RN or LPN may perform sterile procedures. Nurse aides can perform range of motion exercises, as well as shave clients and record vital signs.
Giving good oral care to a client includes all of the following except...
Answer: 4 Oxygen does not interfere with oral hygiene. Gloves should be worn when performing oral care; dentures should be handled and stored correctly; and dental floss should be used when appropriate.
To prevent infection in a client with an indwelling catheter, the nurse aide should...
Answer: 2 Always wipe from front to back to prevent rectal germs from entering the vagina or urinary tract. Keeping the drainage bag higher than the bladder can cause urine to back flow into the bladder, increasing the chance of infection. A U loop may also cause backflow to the bladder, increasing the risk for infection. Perineal care is performed at least daily.
A client is on a clear fluid diet. The client's lunch tray may consist of...
Answer: 1 Clear fluids are see-through. Milk, ice cream, coffee, and crackers are not clear fluids.
Which statement about injuries to clients and staff members is correct?
Answer: 1 Minor and major injuries must be documented. Injuries to staff should never be ignored and should always be treated and reported.
Lying on a job application is an example of...
Answer: 3 Fraud denotes deception. A tort is a wrong that involves a breach of a civil duty. The Joint Commission defines malpractice as "improper or unethical conduct or unreasonable lack of skill by a holder of a professional or offical position." The Joint Commission define negligence as "failure to use such care as a reasonably prudent and careful person would use under similar circumstances."
While shaving a client, the nurse aide accidently nicks the client. The nurse aide should...
Answer: 2 Report it to the charge nurse; a nick can become infected, and all injuries must be reported immediately. Alcohol may sting, and nurse aides cannot apply alcohol without an order. The nurse aide does not report to the physician.
When witnessing another aide hitting an irritable client, the nurse aide should...
Answer: 3 Abuse must be reported immediately. The nurse aide should not directly confront an abusive staff member, and waiting for a few days can risk the abuser injuring another client. Clients should never be hit, regardless of their behavior.
When clients are in a healthcare institution, they can expect their treatment to conform to the...
Answer: 2 The Patient's Bill of Rights is a written statement that includes the rights clients are entitled to when recieving healthcare. The Infection Control Manual and Policy and Procedure Manual do not address client treatment. The Physician Code of Ethics applies only to physicians.
A conversation about a client in the hospital's elevator violates the...
Answer: 1 Conversations regarding a client should never take place in a public area such as an elevator. This violates the client's rights to privacy. This situation does not violate the client's right to receive medical care, to review his records, or to ask questions.
A client constantly makes sexual remarks to staff. When discussing this at a team meeting, the administration decides to instruct staff to call the client by name and tell the client,...
Answer: 2 The staff must tell the client that the behavior is inappropriate. Choice 1 is incorrect; this comment may increase the negative behavior if the client is trying to get a reaction from staff. Choice 3 is incorrect; this comment condones the behavior. Choice 4 is incorrect; this comment belittles the client.
Which of the five senses would best detect a rash?
Answer: 1 Rashes are best detected by observation. Smell may be useful only if the rash is giving off an odor. Touch is only useful if the rash has a definite texture. Hearing is not useful in detecting a rash.
The best way a nurse aide can clean an infant's eyes is with a(n)...
Answer: 2 Infant's eyes are cleaned from inner to outer to prevent the spread of infection. A moist cotton ball is soft and will not injure the eye. Petroleum jelly is not a cleaning agent. Alcohol is not used to clean the eyes, and it can cause chemical damage to them. A hot towel can burn the delicate eyes, and wiping from outer to inner can increase the risk for infection.
A client who is hard of hearing repeatedly turns her light on. When responding to this client's call light, the nurse aide should...
Answer: 1 Listening builds trust, and continuous call bell ringing may have an underlying reason, such as loneliness. Choice 2 is incorrect; a hearing-impaired person may not be able to understand the nurse aide over the call bell system, thus the nurse aide should respond in person. Choice 3 is incorrect; a client must have a way to communicate with staff at all times. Choice 4 is incorrect; the nurse aide should listen to the client to determine the client's needs.
Another employee asks the nurse aide what is wrong with a newly admitted client. What should the nurse aide do?
Answer: 4 The Patient's Bill of Rights assures that client's confidential information is shared only when necessary for care. The nurse aide should not discuss the client at any time with another employee, unless it is directly related to client care. Information is only shared with the immediate healthcare team as needed. The nurse aide should understand client confidentiality.
Most hospital stays are...
Answer: 4 Many hospital stays vary based on the patient's specific diagnosis and procedures. There is no one average hospital stay; the average length depends on the diagnosis.
When caring for a female client, how should the nurse aide address her?
Answer: 4 Clients should be addressed by their surnames (e.g. Mrs. Smith). This shows that the aide respects the client's dignity. "Ma'am" is a term used by military, not by hospital personnell, and "miss" may be viewed as condescending. Using a client's first name may be viewed as a sign of disrespect and should not be done unless requested by the client.
A client is on a low-sodium diet. The nurse aide notes that the client received bacon the the breakfast tray. The nurse aide should...
Answer: 3 The client should not have the bacon. The charge nurse is responsible for contacting the dietician about the error. Choice 1 is incorrect; the client should not have the bacon, but there may be other inappropriate items on the tray. Choice 2 is incorrect; the client may eat it anyway. Choice 4 is incorrect; it is not the nurse aide's role to confer directly with the dietician.
While providing personal care for a client, the nurse aide should...
Answer: 2 Covering the areas of the body that the nurse aide is not working on will allow privacy and keep the body warm. Keeping the client uncovered deprives the client of her dignity, an also can cause discomfort from her being cold. Working under the covers makes care difficult and disallows the nurse aide to observe problems, such as skin redness. The curtain should remain closed, because the client has the right to privacy.
When providing morning (A.M.) care for the client, the nurse aide should...
Answer: 1 Encouraging independence allows clients to feel self-worth by participating in their own care. Choice 2 is incorrect; the nurse aide should foster independence and allow the client to do as much as possible, even if not done correctly. Choice 3 is incorrect; in general, nurse aides cae for clients of both genders; however some cultures require that care be given by persons of the same gender. Choice 4 is incorrect; care should not be rushed.
A client with left-sided weakness should be taught to...
Answer: 2 The client should put the weak arm in the shirt first. Putting the strong arm in first will make it difficult to finish putting on the shirt. It will be too difficult for the client to put both arms into the shirt at the same time. Clients should be encouraged to wear their own clothing to enhance self-esteem and normality.
It is important not to shake linens to prevent the spread of what type of microorganisms?
Answer: 4 Fomites are in or on some hospital equipment. Bacteria, fungi, and ricketsiae may be on fomites.
If a client objects to certain foods for religious or cultural reasons, the nurse aide should...
Answer: 2 Consideration of cultural or religious beliefs is important to all clients. It is not usually necessary to call the physician for cultural preferences. However, if it becomes necessary, this should be handled by the nurse. The client is entitled to have a preferred food right away. However, the nurse aide should inform the nurse of the cultural preference so that the nurse can contact the dietician regarding future meals. Telling a client he will get a tube feeding if he will not eat is abusive behavior and may constitue assault because it is a threat.
A terminally ill resident refuses to bath and throws a water basin across the room. Which stage of dying does this behavior represent?
Answer: 2 The client is in the anger stage of dying, and the nurse aide should acknowledge the client's anger and allow him to talk about it. During denial, the resident will not believe that he is dying. During bargaining the resident hopes that he can somehow postpone death. During acceptance, the resident comes to terms with his mortality.
A terminally ill resident begs, "Please just let me live long enought to see my granddaughter." Which stage of dying does this behavior represent?
Answer: 3 In bargaining, clients "want to make a deal" with someone who may be able to control their fate. The nurse should offer realistic support. During denial, the resident will not believe that he is dying. During anger, the client can be difficult and may act out his anger toward the staff. During acceptance, the resident comes to terms with his mortality.
An important think the nurse aide can do for a dying client is to...
Answer: 2 Physical and emotional support are both vital to terminal clients. Choice 1 is incorrect; the dying client may not want to be alone. Choice 3 is incorrect; fasle hope is inappropriate. Choice 4 is incorrect; dying clients often lose their appetites and should not be forced to eat.
What is most important to show the client in his new room?
Answer: 3 Providing a means to call a nurse is important to avoid injury and meet the client's needs. Choices 1, 2, and 4 are important, but not the most important things for the client to know.
The older adult likes to feel positive about herself by sharing past achievements and experiences. The best way the nurse aide can encourage this is by...
Answer: 3 Listening tells clients you are interested in what they have to say. Choice 1 is incorrect; this is helpful for socialization, but may not be the best way to promote positive feelings. Choice 2 is incorrect; this is helpful, but secondary. Choice 4 is incorrect; this in inappropriate, as nurse aides should listen to their clients.
When caring for a client who is anxious, the nurse aide should do all of the following EXCEPT...
Answer: 2 Forcing an anxious client to stay still may increase the client's anxiety level. You being calm will help the client to become calm, and a quiet environment assists in decreasing anxiety. Anxiety decreases cognition (thinking ability); therefore the nurse aide should speak in a calm, clear, easy-to-understand manner.
A client asks the nurse aide if she could have a few minutes to pray before her bath. The best response by the nurse aide would be to...
Answer: 2 Respecting a client's spiritual needs is an important aspect of the client's care. A client's right to religious beliefs should be respected. Unless specifically requested, clients do not need clergy to pray. Choice 4 ignores both the client's religious beliefs and the client's right to be heard.
During orientation to a new job, a nursing assistant realizes that the work shift ends at 3:30 P.M. and not 3:00 P.M. as previously thought. The nursing assistant's child needs to be picked up every day at 3:15 P.M. The nursing assistant should...
Answer: 1 Being honest and up front with your supervisor is the best approach. Choice 2 is incorrect; a nurse aide cannot ask another nurse aide to cover her work time. Choice 3 is incorrect; this is being dishonest and honesty is a critical quality for healthcare workers. Choice 4 is incorrect; the nurse aide cannot set own her hours; this requires making arrangements with the charge nurse or other appropriate personnel.
The best definition of a certified nursing assistant is...
Answer: 4 This is the only definition of a certified nursing assistant. The nursing assistant is always under the direct supervision of a licensed nurse. Choice 1 refers to a licensed nurse. Choice 2 refers to a licensed dietician. Choice 3 refers to a medical transcriber.
When the nurse aide shows genuine interest and concern for the client, this is an example of...
Answer: 2 Nursing is caring. It is an attitude of interest and concern. Honesty is being truthful in one's words and actions. Teamwork is the ability to work well with others as a team. Accuracy is one's ability to do things correctly.
When giving a bed bath, the nurse aide should...
Answer: 2 Privacy and warmth are in accordance with the Patient's Bill of Rights. Choice 1 is incorrect; when giving a bed bath, the nurse aide should place the bed in a high position to avoid injuring her back through constant bending. Choice 3 is incorrect; the perineal area is washed from front to back. Choice 4 is incorrect; dirty towels and linens are placed in the appropriate receptacle.
An indwelling catheter drains the bladder of...
Answer: 3 A catheter inserted in the bladder drains urine from the body.
The charge nurse asks the nurse aide to place a client in the Fowler's position after the client eats breakfast. How should the aide position the client?
How many stages of death were identified by Dr. Elizabeth Kubler-Ross?
A cane should be used on...
All of the following factors contribute to lack of appetite EXCEPT...
Atrophy is...
The nurse aide, a member of the healthcare team, can participate in many aspects of the nursing process, except for...
When using crutches, the client's weight must rest on the...
How often should a client be repositioned if he cannot move himself?
A client who had a CVA is going through a self-care/grooming program. The main goal of this program is for the client to...
The goal of bladder training is to...
A resident sometime chokes while eating. The nursing assistant should...
If a client complains of a burning, tingling area on her skin, the aide should first...
When changing a pillowcase, a nurse aide should not hold the pillow under his chin because this would...
A nonsterile dressing is one that is...
When asked to clean a resident's eye, the nurse aide should...
One nurse aide is assigned vital signs, while another is assigned bathing. This is an example of which type of nursing?
Gloves must be worn when...
While the nurse aide was caring for a client for four hours, the client asked to be taken to the bathroom every 15 minutes. The nurse aide's best action is...
An elderly resident becomes confused and begins to wander. The nurse aide should...
The Hoyer lift is used for all of the following purposes EXCEPT...
When performing active range-of-motion exercises for a resident, the nurse aide should...
Using a broad base of support means...
If a client is in traction, the nursing assistant should NOT...
Dangling a client's leg over the side of the bed is done to...
Walking with a client is safest if done with a...
When having a client sit up and dangle his legs before walking, the nurse aide should observe for all of the following EXCEPT...
When the nurse aide is transferring a client from the bed to the wheelchair, she should always...
Before any transfer, the nurse aide should do all of the following EXCEPT...
The pulse located in the wrist is called the...
A patient is scheduled for an EKG/ECG. This stands for...
Which of the following sets of vitals should be reported immediately?
A piece of linen that is placed beneath the client from shoulders to thighs is called...
Which bedmaking procedure is used when the client remains in bed?
Which complication may happen if a post-op client does not take in adequate fluids?
Which type of client is most likely to have problems as a result of poor nail care?
When performing mouth care for a client with right-sided weakness, the nurse aide should...
A trochanter roll is used to...
A resident with a paralyzed left arm may be able to feed herself if she uses a(n):
Which statement about residents with developmental disabilities is generally correct?
A diabetic client has had her leg ampulated. Her need for sexuality will...
Client's with Alzheimer's disease may show which of the following symptoms?
If a client is upset and is yelling, the nurse aide should respond by...
A common sign of depression is...
A client who has just been told she is dying asks the nurse aide to help her make a list of things she wants to do before she dies. The nurse aide should...
To assist a client with his psychological needs, the nurse aide should...
A Catholic client refuses to eat meat on Fridays. Her luch one Friday consists of a roast beef sandwiche and a salad. The nurse aide should first...
A nurse aide enters a room and finds a patient having sex with his wife. What should the nurse aide do?
A young, permanently handicapped resident tends to be very quiet and act as if nothing matters. The nurse aide can best show respect for her by...
An example of using body language while communicating is...
A nurse aide smiles and nods her head while sitting with a client. This type of nonverbal communication best demonstrates...
Barriers to effective communication include...
A client's best friend asks the nurse aide what is wrong with the client. The nurse aide's best response is...
A client who is alert and oriented refuses his bath. The best response from the nurse aide is...
An example of false imprisonment is...
Another nurse aide is not providing adequate care for the residents. The nurse aide who notices this should...
A nurse aide notes a bright red rash on a client.This type of observation is termed...
A former union leader was the victim of an industrial accident and is now a resident. To maintain the resident's dignity, the nurse aide may suggest that the client...
A client's daught wants to help with her mother's care. The nurse aide should...
It is important to remember that a client in the last stage of a terminal illness should...
Allowing clients to dress in their personal clothing...
A young, postoperative client has his door closed, and the nurse aide needs to check his vital signs. The nurse aide should... |
What is the FIRST thing a nurse aide should do when finding an unresponsive client
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