Basic Nursing Skills (1)

How many tips does a quad-cane base have? A. 4 B. 3 C. 2 D. 1

A: A quad-cane has four tips to provide a broad base to support the client while walking. The client holds the cane on the strong or unaffected side. To walk, the client should place the cane about an arm's length away, with all four tips touching the ground at the same time. Next, the client should step forward with the weak leg, using the cane for stability.

A client is to be assisted out of bed to sit in a wheelchair. How can this procedure be made safe? A. Place the bed in the lowest position. B. Lower both footrest pedals. C. Place a pillow on the wheelchair seat. D. Release the wheel brakes.

A: Client safety during transfer begins with the bed in the lowest position. This allows the client to easily reach the floor when standing and pivoting to sit in the wheelchair. The brakes of the wheelchair should be locked and the footrests completely out of the way.

A client is paralyzed on the right side. The nurse aide should place the signaling device A. on the left side of the bed near the client's hand. B. under the pillow. C. at the foot of the bed. D. on the right side of the bed near the client's hand.

A: Clients who have had a stroke often have one-sided weakness or paralysis. They may not be able to use that side of their body, or they may not even be aware of the affected side. This is called "one-sided neglect." Rehabilitation services will help the patient recover as much as possible. As the client's caregiver, you can encourage the client to use the unaffected side by placing the signaling device where the client can reach it to call for assistance.

If the nurse aide discovers fire in a client's room, the FIRST thing to do is A. remove the client. B. open a window. C. try to put out the fire. D. call the nurse in charge.

A: The nurse aide should be familiar with all fire safety policies and protocols. If a fire alarm sounds, all staff must respond to keep clients safe. Remember "R.A.C.E." to quickly act. R = Rescue/Remove all people who can not take care of themselves. A = Alarm, if it has not already been done. Pulling the alarm can be done at the same time as rescue. C = Confine/Contain the fire or smoke by closing doors to prevent or slow the spread. Smoke is especially dangerous for everyone. E = Extinguish the fire if possible, using a handheld fire extinguisher. Only try to extinguish small fires and only as long as you can remain safe and have an escape route.

To convert four ounces of liquid to milliliters (ml), the nurse aide should multiply 4 by A. 30 ml. B. 5 ml. C. 10 ml. D. 15 ml.

A: When converting milliliters (ml) to ounces (oz), remember that one ounce is approximately 30 ml. Although one ounce is slightly less, the amounts are considered equal by doctors and pharmacists.

The nurse aide is going to help the client walk from the bed to a chair. What should the nurse aide put on the client's feet? A: Rubber-soled slippers or shoes B: Socks or stockings only C: Nothing D: Cloth-soled slippers

A: When helping a client ambulate, you must prevent the client from falling. Proper footwear should always be worn for any type of walking, even a short distance. Rubber-soled slippers or shoes provide traction to prevent falls. Socks, stockings, or slippers made from fabric can make the client slip or lose his or her balance. Walking in bare feet can lead to foot injuries, which is especially dangerous for diabetic clients.

The electric shaver that the nurse aide is using to shave a client begins to spark and smoke. What should the nurse aide do FIRST? A. Unplug the shaver. B. Use the roommate's shaver to finish the shave. C. Finish shaving the client as quickly as possible. D. Call the nurse in charge.

A: Whenever you give a client care, remember that the patient's safety comes first. Unplug a malfunctioning device to stop sparks or smoke. If the client or anyone nearby is on oxygen, the sparks could trigger a fire, so you may need to move people out of the area quickly. After everyone is safe, notify the nurse of the incident. Never use another client's personal items; this is strictly prohibited because of the risk of infection.

Physical restraints are used MOST often A. at the roommate's request. B. to prevent client injury. C. at the family's request. D. when staff is short.

B. Physical restraints are devices or equipment that prevent normal movement. Examples are arm or leg restraints, hand mitts, and vests. It is against the law to use restraints unless they are necessary to treat a client's medical symptoms or there is a risk of harming oneself or others. Restraints may not be used for punishment, convenience, or control. Either a physician's order or the client's consent is required before a restraint can be applied.

For safety, when leaving a client alone in a room, the nurse aide SHOULD A. keep the door tightly closed. B. place the signaling device within the client's reach. C. apply a restraint to the client. D. leave the bed elevated in the highest position.

B: After giving care, or when leaving the client's room, always ensure that the client's call signal is within reach. Clients must always have access to caregivers. For safety, the bed should be in the lowest position, with the bed rails up. Restraints may never be applied without an order from the client's doctor.

The equipment you need for oral care of an unconscious client includes A. toothpaste. B. toothette/mouth swab. C. toothbrush. D. all of the above.

B: Because an unconscious client is not able to assist with oral care, you must take extra precautions to prevent the client from choking or aspirating. The client's head should be turned to the side. If possible, lower the head of the bed. Gently clean the teeth and gums with a separate moist toothette or mouth swab for each area of the mouth. When you've finished, wipe the client's mouth and raise the head of the bed to its previous position.

A client needs to be repositioned but is heavy, and the nurse aide is not sure that she can move the client alone. The nurse aide should A. have the family do it. B. ask another nurse aide to help. C. go on to another task. D. try to move the client alone.

B: Clients or objects that are heavy should never be moved or lifted by one person. The risk of falls or injuries to both the client and the nurse aide increases with heavy loads. Ask for assistance before attempting to pull or roll a heavy patient. Use good body mechanics by using your leg muscles to avoid back injury.

Insulin, a hormone, regulates A. the amount of salt retained in the blood. B. the amount of sugar in the blood. C. the rhythm of the heart. D. the strength of the skeletal muscles.

B: Diabetes is a disease that results when the pancreas does not make enough insulin to decrease or control the amount of sugar in the blood. Clients with diabetes must check their blood sugar levels every day. To stay healthy, they require medication, which can include insulin injections.

While making an empty bed, the nurse aide sees that the side rail is broken. The nurse aide SHOULD A. wait for the next safety check to report the broken side rail. B. report the broken side rail immediately. C. tie the side rail in the raised position until it is fixed. D. warn the client to be careful when he or she gets back into bed.

B: Every staff member is responsible for keeping clients safe at all times. This includes monitoring all equipment and reporting when anything needs repair. Never use broken equipment or try to create a temporary fix for equipment that is not working properly. Tag the broken bed and move it so that another client can't use it. Replace it immediately with one that has functioning side rails.

NPO means A. Only ice chips in mouth B. Nothing by mouth C. Nothing per ostomy D. Nothing by mouth except water

B: NPO is a common medical term that means the client can not eat or drink anything, including water or ice chips. A doctor may order a patient to be NPO before surgery or certain lab work. If a client is ill or has a gastrointestinal condition, the doctor may write an order that the client be NPO until the cause is known. The nurse aide can provide mouth care for a client who is NPO. Placing an "NPO" sign over the client's bed will remind all staff members not to give the client anything to eat or drink.

Clean bed linen placed in a client's room but NOT used should be A. taken to the nurse in charge. B. put in the dirty linen container. C. used for a client in the next room. D. returned to the linen closet.

B: Once linen has been in a client's room, it is no longer considered clean. Each client's room may have pathogens or sources of possible infection that can be spread by objects from that room. Opened supplies or items with sterile packaging that has been opened should also be discarded, even if they have not been used.

The Heimlich maneuver (abdominal thrusts) is used on a client who has A. a bloody nose. B. a blocked airway. C. impaired eyesight. D. fallen out of bed.

B: The Heimlich maneuver (abdominal thrusts) is a first aid technique for helping someone who has food or an object caught in his or her upper airway. When a client appears to be choking, you must act quickly to clear the airway. First, call for help. Next, to perform abdominal thrusts, stand behind the client. Make a fist with your dominant hand. Place this fist just above the client's navel. Wrap your other hand firmly around the fist. Pull inward and upward, pressing into the client's abdomen with quick and forceful upward thrusts as if you were trying to lift the client off his or her feet from this position. Continue the abdominal thrusts in quick succession until the object is expelled.

When caring for a client who uses a protective device (restraint), the nurse aide SHOULD A. ensure the protective device is tight. B. check the client's body alignment. C. assess the client once every hour. D. release the protective device once per shift.

B: When a physician orders a restraint for a client, the staff must strictly follow the protocols to maintain the client's safety. The nurse aide should become familiar with the policies regarding restraints. The policy will state the defined times to monitor the client, directions for reporting on the client's status, and directions for documenting all observations.

What is the FIRST thing a nurse aide should do when finding an unresponsive client? A. Call the client's family. B. Call for help. C. Close the door. D. Start compressions.

B: When encountering any type of emergency situation such as an unconscious client, always call for help first. Others can clear the area, phone for an ambulance, assist with CPR, help move or transfer the client, or document the events.

Which of the following best helps reduce pressure on the bony prominences? A. Sheepskin B. Repositioning every shift C. Flotation mattress D. Several pillows

C: A bedridden client can quickly develop pressure sores if he or she is allowed to remain in one position. To prevent the skin from breaking down, reposition the client at least once every two hours. Use pillows to support the client and relieve places where skin can rub, such as between the legs or at the tailbone. Always keep the skin clean and dry. A sheepskin on the bed or wheelchair provides extra padding but does not replace repositioning. Observe the skin for reddened areas and report them to the nurse. Special beds and flotation mattresses are helpful in preventing pressure sores.

When taking a client's radial pulse, the nurse aide's fingertips should be placed on the client's A. chest. B. elbow. C. wrist. D. neck.

C: A radial pulse is found at the client's wrist. To locate it, place your index and middle fingers on the hollow area below the thumb. Apply light pressure to feel the pulse. Count each beat for 30 seconds and multiply by 2 to get the pulse rate. If the client has an irregular heartbeat, count for 60 seconds. Record the pulse rate on the client's chart.

The nursing care plan states, "Transfer with mechanical lift." However, the client is very agitated. To transfer the client, the nurse aide SHOULD A. lift the client without the mechanical device. B. keep the wheels unlocked so the lift can move with the client. C. get assistance to move the client. D. place the client in the lift.

C: Client safety is always your highest priority. Do not try to accomplish a task alone if a patient is unable to cooperate for any reason. It is important to follow the nursing care plan, including all the steps for operating any equipment being used to move or transfer the client. Ask a co-worker to help if you have any concerns about keeping the client safe. If the client remains agitated, notify the nurse before proceeding.

The nurse aide sees a client spill water on the floor in the hall. Another client is walking down the hall. The nurse aide SHOULD A. leave the spill. B. call the nurse. C. clean up the spill. D. call housekeeping.

C: Falls can lead to serious injury and complications, especially among elderly or very ill clients. Every staff member should be constantly alert for potential hazards such as spills and immediately take care of the situation. Never ignore a potential cause of a fall. If the spill is caused by blood or body fluid, follow the protocol for decontamination and wear Personal Protective Equipment (PPE).

To be sure that a client's weight is measured accurately, the client should be weighed A. by a different nurse aide. B. after a good night's sleep. C. at the same time of day. D. after a meal.

C: Obtaining the client's weight is an important part of assessment. Weight should be measured at the same time every day. Morning is the best time. Ideally, to get the most accurate or dry weight, use the same scale each time and weigh the client after the first void and before breakfast.

The purpose of padding side rails on the client's bed is to A. keep the client warm. B. use them as a restraint. C. protect the client from injury. D. have a place to connect the call signal.

C: Side rails can keep clients from falling out of bed. Also, clients can grab on to the railing to reposition themselves. However, if the client is agitated, confused, or has a head injury or a history of seizures, padding the side rails can prevent injuries or entrapment. Some facilities have bed rail pads or bumpers in stock. You can also use a mattress pad to make a side rail pad. Make sure the bed is always in the lowest position.

The nurse aide is walking with a client confined to a wheelchair when the facility fire alarm system is activated. The client becomes excited from the noise. The nurse aide SHOULD A. push the wheelchair out of the hallway and carry the client out of the facility. B. lock the client's wheelchair and check the surrounding area for smoke. C. comfort the client while moving the person to a safe place. D. leave the client to search for help.

C: The nurse aide should be familiar with all fire safety policies and protocols. When a fire alarm sounds, all staff must respond to keep clients safe. Remember "R.A.C.E." to quickly act. R = Rescue/Remove all people who can not take care of themselves. A = Alarm, if it has not already been done. Pulling the alarm can be done at the same time as rescue. C = Confine/Contain the fire or smoke by closing doors to prevent or slow the spread. Smoke is especially dangerous to everyone. E = Extinguish the fire if possible with a handheld fire extinguisher. Only try to extinguish small fires, and only as long as you can remain safe and have an escape route

To take an oral temperature, the nurse aide should A. place the thermometer under the arm. B. put lubricant on the thermometer. C. place the thermometer under the tongue. D. place the thermometer in the rectum.

C: To take an oral temperature, make sure the client has not had anything hot or cold to eat or drink for 15 minutes. Place the thermometer under the client's tongue. A digital thermometer will beep when it registers the client's temperature. A glass thermometer will have a line that stops moving when it gives the reading. Note: The normal body temperature ranges for very young children, older children, and adults are different. For children aged 2 - 5 years, the normal body temperature range is 37.0°C - 37.2°C (98.6°F - 99.0°F). For children aged 5 - 10 years, the normal range is 35.5°C - 37.5°C (95.9°F - 99.5°F). For persons age 11 and up, fever is considered a temperature higher than 38 degrees C (100.4°F).

Which of the following is the most comfortable position for a client with a respiratory problem? A. Supine B. Prone C. Fowler's D. Lateral

C: When a client is having difficulty breathing, the Fowler's position can provide relief. When sitting in the Fowler's position, the client is upright at 90 degrees, allowing the chest to expand as much as possible. Prone (on the abdomen), supine (on the back), and lateral (on the side) are all flat positions, which can make respiratory distress worse.

To lift an object using good body mechanics, the nurse aide SHOULD A. keep both feet close together. B. hold the object away from the body. C. bend the knees and keep the back straight. D. lift with the abdominal muscles.

C: When lifting, you should maintain proper spinal position. The risk of injury to the lower back increases if you use the back muscles, bend at the waist, twist, or try to lift a load that is too heavy. Common injuries associated with lifting are strains, sprains, and herniated discs. For heavy loads, always find another person to help.

When transferring a client, MOST of the client's weight should be supported by the nurse aide's A. shoulders. B. back. C. legs. D. wrists.

C: When transferring a client, position yourself to support the client by using your legs. Keep your back straight and locked; do not turn or twist. If you bend, do so at the hips, not the waist. Before beginning the transfer, assess how much the client is able to do. If you have any doubts, always ask for assistance from a co-worker.

When operating a manual bed, the nurse aide should remember to A. keep the client's head elevated at all times. B. keep the bed in the neutral position. C. fold the cranks under the bed. D. lock the wheels when the cranks are folded.

C: When working a manual bed, first lock the bed by pressing down the levers on the wheels at the head and foot of the bed. At the end of the bed there are three cranks which control the bed height, as well as raising and lowering the head and feet. Cranks are turned clockwise (left to right) to raise each section, and counterclockwise to lower it. After positioning the client, always fold the cranks under the bed to prevent others from tripping or falling.

The nurse aide is responsible for the following fire prevention measures EXCEPT A. reporting all damaged wiring or sockets in clients' rooms. B. being aware of the locations of fire extinguishers. C. taking cigarettes and matches away from all clients and visitors. D. participating in fire drills.

C: While smoking by clients and visitors may not be appropriate, the nurse aide may not take away their cigarettes or matches. However, the nurse aide can certainly report these actions to the charge nurse. The nurse aide should also be familiar with policies regarding smoking or smoking areas, to inform smokers if there are designated places. All staff must be aware of fire extinguisher locations and what to do in the event of a fire. Notifying the nurse or maintenance department of any damaged electrical wiring or sockets, as well as faulty electrical equipment can prevent a fire.

Which of the following is a correct measurement of urinary output? A. 1 quart B. 2 cups C. 40 oz D. 300 cc

D: 300 cc is a metric measurement meaning 300 cubic centimeters. In medicine around the world, the metric system is used for all length, weight, volume, and temperature measurements. The metric system is based on powers of ten, making it simpler and more precise than other methods of measurement.

What is the term for a device used to take the place of a missing body part? A. Abduction B. External rotation C. Pronation D. Prosthesis

D: A prosthesis is a device that replaces a part of the body that is missing from birth or due to surgery or accidents. It helps restore function for the client and can also improve a client's appearance. A prosthesis can be made for eyes, teeth, arms, legs, joints, or breasts.

Which of the following is NOT considered a way to restrain a client? A. A hand mitt B. A sedative C. Lap buddy/tray D. Pain management

D: A restraint may be either physical or chemical. Its purpose is to protect the client from harming himself or others. Only a physician may order a restraint, and guidelines are strict. A pain medication may help calm a client or relieve behavior associated with severe pain, but it is not in the restraint category.

While eating dinner, a client starts to choke and turn blue. The nurse aide SHOULD A. immediately remove the client's food tray and go find the nurse in charge. B. slap the client on the back until the food dislodges. C. give the client a drink of water. D. call for assistance and perform the Heimlich maneuver (abdominal thrusts).

D: Abdominal thrusts (the Heimlich maneuver) is the best response to choking. Calling for assistance as you prepare to do abdominal thrusts will alert others to the emergency. You can try a quick back slap, but if the food is not immediately dislodged, quickly start abdominal thrusts. To perform abdominal thrusts, stand behind the client and use your hands to exert upward pressure on the bottom of the diaphragm.

To avoid pulling on the catheter while you're turning a male client, the catheter tube must be taped to his A. hip. B. bed frame. C. bedsheet. D. upper thigh.

D: An indwelling urinary catheter is used to drain the bladder into a bag outside the body. A catheter for males is a long tube with a balloon that is inflated after being inserted. The tube that drains the urine must not be tugged on or become kinked. In males, it is attached to the client's inner thigh by tape or a special fastening device. Never attach the tube to anything except the client's inner thigh. The drainage bag should remain lower than the client's bladder to prevent a backflow of urine.

Which type of fire can be put out with water? A. Electrical B. Grease C. Chemical D. Paper

D: Fire extinguishers are classified by the materials they can snuff out. Think "ABC." Class A fire extinguishers are used for paper, wood, textiles, and some plastics. Class B extinguishers are used for flammable liquids such as oil or gasoline. Class C extinguishers are for electrical fires. All fire extinguishers have labels on them to identify which type of fire they can be used on. Never use water on an electrical fire because of the risk of electric shock.

Which of the following people provide treatment for persons who have difficulty talking due to disorders such as a stroke or physical defects? A. Physical therapist B. Registered nurse C. Occupational therapist D. Speech therapist

D: If a client is unable to speak clearly or has trouble forming words, a speech therapist can alleviate speech problems caused by strokes, physical defects, or swallowing disorders. Speech therapists work with both adults and children. They are qualified to evaluate, diagnose, and treat clients

When helping a client who is recovering from a stroke to walk, the nurse aide should assist A. from behind the client. B. on the client's strong side. C. with a wheelchair. D. on the client's weak side.

D: When helping a client who is recovering from a stroke to walk, you should stay on the client's weak side. Walk next to and slightly behind the client to be ready to suddenly support the weak side. If the client is using a walker or cane, allow space for the device. While walking, be alert to avoid possible fall hazards. The client should wear slippers or shoes with rubber soles for traction.

The nurse aide notices that the client's radio cord is draped across a chair to reach the nearest outlet. The FIRST thing the nurse aide should do is A. unplug the radio and ask the client not to use it. B. take the radio to the activities room and tell the client to listen to it there. C. see if any changes can be made so that the radio can be plugged in safely. D. tell the client the radio is a safety hazard and take it away.

c: All facilities must comply with the electrical safety standards of governmental and accrediting agencies. Client devices, including radios or televisions, must be approved according to the facility's policies. Cords cannot cause any potential hazards, such as tripping or falls. Extension cords are usually not allowed. The nurse aide can help the client find a place for the radio where the cord to be safely plugged in, so the client can continue to enjoy listening.