Basic Nursing Skills (2)
Most of our calories should come from A. fats. B. protein. C. carbohydrates. D. vitamins.
C: A balanced diet is essential for health. When the client consumes nutrients in the right combination of calories, the person's desired weight is maintained. Carbohydrates supply fuel for the body, so 45 - 65% of calories should come from carbohydrates. The energy is stored in the muscles and liver for immediate or future use, as well as for the brain to function. Fat and protein have important roles, but they are not good as energy sources.
Which of the following should be reported immediately? A. A pulse of 90 B. Respirations of 12 C. A blood pressure of 90/40 D. Temperature of 99.4°F
C: Low blood pressure (hypotension) is less than 90/60. Only one of the numbers has to be lower to be considered hypotension. Some clients may have a normal blood pressure in the low range, but if there is a sudden drop from usual, immediately report it to the nurse.
In a report, the nurse aide is told that one of her patients has been ordered NPO after midnight. The aide should A. ask the patient if he or she is having any pain. B. note all water that the patient drinks and all output. C. take away the water pitcher at midnight. D. offer frequent snacks.
C: 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. The nurse aide can provide mouth care for a client who is NPO. Placing an "NPO" sign over the client's bed and on the client's door will remind all staff members not to give the client anything to eat or drink.
Signs and symptoms of shock may include A. hyperventilation. B. increased blood pressure; bradycardia; and flushed skin. C. low blood pressure; tachycardia; and clammy, pale skin. D. absence of respiration and pulse.
C: Signs of shock include low blood pressure (hypotension); a rapid heart rate (tachycardia); a weak pulse; and pale skin, which can be damp or clammy. The client may be breathing rapidly (hyperventilation). The client may also be confused or not alert. Shock is an emergency situation requiring rapid treatment.
What is the best way to keep a skilled nursing facility from having an unpleasant odor? A. Empty bedpans and change linens in a timely manner. B. Keep all the windows open. C. Use an air freshener regularly. D. There is nothing you can do.
A: All staff in a skilled nursing facility are responsible for maintaining a pleasant environment. Any source of odor must be dealt with at once. Bedpans and commodes should be emptied and cleaned as soon as the client finishes. All linens should be changed in accordance with the facility's policies and as needed. Soiled linens should be transferred to the laundry facilities as soon as possible. Housekeeping can clean the common areas, dining room, and client rooms to prevent odors from food or incontinent episodes.
A patient who was given insulin in the morning is pale and sweaty and appears confused two hours later. It would be helpful to find out whether the patient A. had breakfast. B. had visitors that day. C. ate too much sugar. D. has diabetes.
A: Diabetic clients have a strict schedule regarding insulin injections and eating. Eating causes blood sugar to rise, and the insulin helps move it into the cells. Without food, the blood sugar drops quickly, causing a serious situation. Immediate treatment is necessary. Quickly check the client's blood sugar level and report it to the nurse. The client will need to eat 15 grams of glucose or a simple carbohydrate such as 1/2 cup orange juice or a tablespoon of sugar. The nurse aide should be aware of which clients are diabetic so that meals are served shortly after the clients receive insulin.
In the Nursing Care Plan, you note that it is written, "O2 per N/C @3L, Orthopnea pos. as needed". As a CNA, you know that this means which of the following? A. The resident is on oxygen with a nasal cannula on three liters. Assist to sit in Fowler's position. B. Oral care must be performed every three hours. C. Orient the new client @ 3:00 to orthopedic unit. D. The resident is to be ambulated every three hours.
A: Every facility has a list of approved abbreviations. The CNA should become familiar with these, for reading care plans and for preparing documentation. This nursing care plan means that the client is receiving oxygen at a constant rate of 3 liters per minute, using a nasal cannula. If the client has difficulty breathing, the CNA can assist the client to sit in a Fowler's (upright) position.
Which of the following measurements that you obtained from Mrs. Shumway should be reported immediately to the charge nurse? A. B/P 190/114 B. Respiration 20 C. Pulse 74 D. Temperature 99°F
A: Hypertension is defined as a blood pressure over 140/90. Severe hypertension is above 180/120. Even if the client has a history of high blood pressure, always immediately report a sudden increase to the nurse. Untreated hypertension can lead to heart disease and stroke.
A patient complains that her hand hurts where the IV is running. The nurse assistant notices that the hand is puffy. The nurse assistant should A. notify the IV nurse that the infusion appears to have infiltrated. B. reassure the patient that needles always hurt. C. put ice on the hand. D. notify the medication nurse that the patient is complaining of pain.
A: Infiltration occurs when the IV fluid leaks into the tissue because of a dislodged or misplaced IV catheter. The nurse assistant should monitor the IV site and report if it becomes swollen, cool to the touch, or painful. The skin near the IV site may look pale. Always be careful when moving or assisting a client with an IV to avoid pulling the line.
Which of the following statements about blindness are false? A. Most legally blind or visually impaired people have no sight at all. B. Diabetes is an important cause of blindness. C. Ask if a blind person needs help before you give assistance. D. Always identify yourself before touching a blind person.
A: People who are legally blind or visually impaired may still be able to see, but images can be quite blurry even when they're wearing glasses. They have difficulty reading and are restricted from such activities as driving. Another disability results from tunnel vision. A person with this condition can only see straight ahead, lacking peripheral vision to see almost 180 degrees. Only about 10 - 15% of people who are diagnosed as blind see nothing at all.
Postpartum refers to A. The period of time after the delivery of a baby B. The period of time right after death C. The period of time just before death D. The period of time right before the delivery of a baby
A: Postpartum is a medical term that means "after giving birth." In any medical term, the prefix "post" always means "after." For example, postoperative means "after surgery" and postdischarge means "after leaving treatment." The term "partum" refers to giving birth.
Meal trays have arrived. Before serving each tray, the nurse aide should A. check each armband, even on familiar patients. B. check the temperature of the food. C. ask patients if they are hungry. D. ask about dietary restrictions.
A: Some clients have special diets, severe food allergies, or strict fluid restrictions. Before serving a meal tray, always check the client's ID band or tag and match it to the correct tray. Although it can be tempting to skip this step in a long-term care facility, the nurse aide is legally responsible for verifying the identity of each client before serving food or giving care.
Which of the following is the recommended position for giving an enema? A. Left Sims B. Prone C. Semi-Fowler's D. Supine
A: The left Sims position is used for rectal examinations and administering enemas. The client lies on the left side, with the right knee and hip bent. This position is also called the lateral recumbent or semiprone side position.
A professional and safe working appearance would include which of the following? A. Clean, wrinkle-free uniform; short fingernails; and off-the-shoulder hair B. Carefully manicured acrylic nails C. Sandals, T-shirt, and a name tag D. Jewelry that reflects your fun personality
A: The nurse aide is considered a health care professional and should dress accordingly. Each facility has a dress code policy regarding the type of uniform to wear. Clothing must be clean and free from stains, tears, or wrinkles. Shoes must be closed toe with non-skid soles. Appropriate grooming is always necessary. To prevent a nurse aide from injuring a client while giving care, the nurse aide's jewelry is usually limited to a watch and a wedding ring. A name tag is part of the standard uniform.
Normal urine color is A. colorless. B. brown. C. red. D. yellow.
D: Normal urine has a yellow color that ranges from dark yellow to light straw color. Urine that is amber-colored indicates dehydration; more fluids need to be taken. Brown urine can mean severe dehydration or liver disease, and should be checked. Red-tinted urine can occur after the client eats certain foods, such as beets or blueberries. Red urine can also be a sign of kidney disease, urinary tract infection, or prostate problems. Colorless urine may mean that the client is overhydrated and should reduce fluid intake.
When caring for a resident with an indwelling Foley catheter, you should A. check the bag and tubing frequently for adequate urinary flow. B. tuck the tubing under the resident's leg to keep it off the floor. C. pin the tubing to the resident's gown. D. withhold fluids if the bag is too full.
A: When a client has an indwelling Foley catheter, the nurse aide should check that the tubing is open so that the urine can flow from the bladder. After each position change or whenever the client returns to the bed or chair after being up, ensure that the tubing is not kinked or closed. Finally, the bag should be lower than the bladder to prevent backflow.
A patient has a diagnosis of psoriasis. Her nurse aide should A. avoid contact with the highly contagious lesions. B. treat her the same way as any other patient with a non-infectious disease. C. wear gloves for patient care. D. wear a mask when entering the room.
B: Autoimmune diseases are never contagious. They happen when the body's immune (defense) system attacks its own healthy tissue by mistake. Besides psoriasis, other autoimmune diseases include lupus, celiac disease, multiple sclerosis, and type 1 diabetes. Client care is the same as for any other client without an autoimmune disease.
Your resident consumed a bowl of soup that was 180 cc of liquid. How many ounces was that? A. 7 oz. B. 6 oz. C. 4 oz. D. 5 oz.
B: 180 cc = 6 oz. When converting cubic centimeters (cc) to fluid ounces (oz), remember that 30 cc = 1 ounce. Although an ounce is slightly less, the amounts are considered equal by doctors and pharmacists. Also, 1 cc = 1 ml.
To take a rectal temperature, the nurse aide should insert the thermometer and A. stay in the room until it is time to read the temperature. B. hold on to the thermometer until it can be removed. C. go on a break. D. take care of other patients, returning in three minutes.
B: A rectal reading is the most accurate way to measure body temperature, but it needs to be done correctly. After placing the client in the Sims position, lubricate the thermometer and gently insert it about one or two inches into the rectum. Hold the thermometer in place for two minutes to prevent it from being pushed out or advancing into the rectum. After withdrawing the thermometer, wipe it with a gauze pad, read the temperature, and place the thermometer in the "used" container.
The opening of the colostomy to the outside of the body is called A. the rectum. B. the stoma. C. the insertion site. D. none of the above.
B: A stoma is an artificial opening in the body, created surgically. To create a colostomy, the surgeon brings the end of the colon through the abdomen and creates a mouthlike opening that will drain waste into a bag. A stoma can also be created for the bladder or the ileum (the lowest part of the small intestine).
Mrs. Shumway's nursing care plan lists CHF (Congestive Heart Failure) as her primary dx. (diagnosis). You would expect her ADL routine to include which of the following? A. Encouraging oral fluids B. Daily am weight measurement C. Placement of TED hose after ambulation D. Daily jog around the facility for one hour
B: Congestive heart failure is a chronic disease that occurs when the heart becomes weak and is no longer able to pump efficiently. It is important to monitor the client's weight. A sudden weight gain means that the client is retaining fluid. This puts a strain on the heart and lungs. The nurse aide should weigh the client every morning at the same time and record the weight. Notify the nurse of any sudden change.
The circulatory system consists of the A. blood vessels, arteries, veins, and capillaries. B. heart, arteries, veins, and capillaries. C. heart, aorta, pulmonary vessels, and lungs. D. blood vessels, lymph nodes, and spleen.
B: The circulatory system is made up of the heart, arteries, veins, and capillaries. They are connected to make a complete circuit in the body. The heart pumps oxygenated blood from the lungs, as well as nutrients, through the arteries to the capillaries. The capillaries then deliver carbon dioxide and waste to the veins. The veins take the waste products to the liver and kidneys for disposal, and the carbon dioxide goes to the lungs to be exhaled.
On which side should the patient lie for an enema? A. Whichever side is more comfortable B. Left C. Right D. The side closer to the restroom
B: The left Sims position is used for rectal examinations and administering enemas. The client lies on the left side, with the right knee and hip bent. It is also called the lateral recumbent or semiprone side position.
You are caring for Mr. Brown, who has a diagnosis of COPD. His SpO2 is 82%. He is currently receiving O2 via Nasal Cannula @ 2 liters/min. What do you do? A. Turn up the O2 to 4 liters/min. B. Report it STAT to the nurse. C. Switch the nasal cannula to a mask. D. Ask Mr. Brown to take breaths more frequently.
B: The normal SpO2 range for a client with Chronic Obstructive Pulmonary Disease (COPD) is 88-92%. This is because oxygen reaches the lungs but lung damage prevents oxygen from getting into the blood. For clients with COPD, giving oxygen is carefully regulated with limits according to how the oxygen is delivered. Immediately report a low saturation to the nurse. Do not make any changes on your own.
A resident with an ileostomy evacuates feces through the A. anus. B. colon. C. ileum. D. jejunum.
C: The ileum is the lowest part of the small intestine. An ileostomy is an opening in the abdomen that is created during surgery. The end of the ileum is placed outside the body and connected to a bag that collects the waste of the intestine. The ileostomy is usually on the lower right side of the body.
The brain is part of the A. locomotor system. B. endocrine system. C. nervous system. D. exocrine system.
C: The nervous system has two parts. The brain and spinal cord make up the central nervous system (CNS). The peripheral nervous system (PNS) is made up of all the body's nerves, which connect to the CNS. The brain sends messages through the spinal cord and nerves to control the body's muscles and organs. It also processes and interprets the information from both inside and outside the body.
A nurse aide notices blood in a patient's IV tubing. The aide should A. try to flush the tubing. B. do nothing; that's normal. C. stop the IV. D. notify the IV nurse.
C: When an IV is running well, the tubing should be clear and the IV site clean and dry. If you notice blood in the tubing, notify the nurse. It is beyond the scope of practice for a nurse aide to do anything with an IV.
A patient appears paler than usual. The nurse aide should A. note it on the chart. B. offer the patient a glass of water. C. ask the patient how he feels and take his vital signs immediately. D. get the patient a snack.
C: Whenever you notice a change in the client's condition, stop to assess the client and take vital signs. If the client is able to respond, ask the person how he or she feels. Report the change, vital signs, and client's response to the nurse. When charting, document what you observed and did.
Mrs. Sparks is an 83-year-old female patient who suffers from the late effects of a CVA. She has {L} sided hemiplegia. This is A. L arm and leg itching. B. a rash on the L arm. C. an L arm contracture. D. paralysis on the left side of the body.
D: A client with left-sided hemiplegia has paralysis on the left side of the body. The paralysis can be either partial or total. It occurs on the opposite side of the CVA (stroke) or brain disorder. Mrs. Sparks had a CVA on the right side of her brain, resulting in left-sided paralysis.
A nurse assistant notices red marks on a resident's back and buttocks. The aide acts in the knowledge that A. red marks are not a problem. B. it takes a doctor's order to rub skin with lotion. C. patients can only be turned every two hours. D. the skin can break down if nothing is done.
D: A reddened area is the first sign of skin breakdown. It means that there is pressure and a lack of blood circulation to the area. The nurse aide should immediately reposition the client to eliminate pressure. Clients who are not mobile need to be repositioned at least every two hours. Never massage a reddened area, because this will only increase the damage. Keep the client clean from perspiration, urine, and feces. Continue to observe the skin and report to the nurse if the marks do not quickly disappear.
Which of the following is the safest way to confirm a resident's identity? A. Call the resident by name and see if the person answers. B. Look at the door number and compare it to your room list. C. Ask the resident's roommate. D. Check the ID bracelet or tag attached to the resident.
D: Accurate identification of a resident is always done by checking the resident's ID bracelet or tag. This is a universal standard of practice in every facility and health care setting. It ensures that the resident receives the correct treatment and care every time.
Mrs. Hernandez had a hip replacement and is admitted to the long-term care facility for rehabilitation. Her condition is considered A. chronic. B. obstetric. C. tonic. D. acute.
D: An acute event is a new or sudden situation that is expected to resolve. Examples are a broken bone, a head cold or the flu, or an asthma attack. In this question, Mrs. Hernandez has an acute condition because she will be leaving the long-term care facility after she finishes rehabilitation. A chronic condition develops slowly and continues to progress. Examples are heart disease, diabetes, and osteoporosis.
The charge nurse has asked you to take Mrs. Shumway's vital signs. Before doing so, you must A. wash your hands. B. identify the patient and introduce yourself. C. gather all appropriate equipment. D. do all of the above.
D: Before providing any care, the nurse aide must perform all the standard steps in preparation. ALL the standard steps must be performed before proceeding, not just one. Gather everything you'll need so you won't have to leave the client's room once you begin. Always wash your hands before and after each client interaction. Knocking before entering the client's room, introducing yourself, identifying the client, and explaining what you will be doing are also part of standard practice.
Before performing any procedure, a nurse aide must A. identify the patient. B. explain the procedure. C. wash his or her hands. D. do all of the above.
D: Clinical standards require all health care professionals to identify the client by checking the ID band or tag before providing care. They should wash their hands both before and after an encounter with a client. They should also explain what they are going to do and give the client an opportunity to ask questions before proceeding.
Drainage bags from urinary catheters should always A. have their output measured each week. B. be fastened securely to the bed frame. C. be changed every shift. D. be kept below the level of the bladder.
D: Drainage bags from an indwelling Foley catheter should be kept below the the level of the bladder to prevent urine from backflowing into the bladder. It also allows gravity to help drain the tubing. Always check that the tubing is not kinked or compressed. Depending on the reason for the catheter, urine may have an unusual appearance; ask the nurse what is abnormal for the patient. Monitor and record the color of the urine as well as observations such as sediment, cloudiness, or blood. Follow your facility's policy or the patient's care plan regarding how often to change the urinary drainage bag.
Continuing education is A. important for keeping abreast of new developments. B. a professional standard. C. necessary for recertification in many states. D. all of the above.
D: For health care professionals, learning does not end at graduation. Medicine is constantly changing, and it is the responsibility of each person to be aware of new developments in their area of practice. Also, clinical standards and many states require proof of continuing education in order to renew a license or certification. During an accreditation survey, hospitals and facilities must show proof that staff members are receiving ongoing training and education.
Who can order a warm or cold application? A. You as a CNA (if you think it is necessary) B. A nurse C. The director of nursing D. A doctor
D: It is important to remember that only a doctor can order a treatment, test, or medication for a client. This includes even simple treatments such as hot and cold compresses. A nurse aide can be fired or lose certification for initiating treatments.
To help ensure adequate circulation to prevent patient skin breakdown, you should A. give back massages. B. change the patient's position frequently. C. perform active or passive range-of-motion exercises. D. do all of the above.
D: One of the primary responsibilities of a nurse aide is to monitor the client's skin for any signs of breakdown. During baths, dressing, or position changes, inspect the skin for redness, pallor, warmth, or bruising. Reposition at least every two hours, protecting areas that rub together, as well as the bony prominences. Massages of the back and buttocks can promote circulation. Range-of-motion exercises are also helpful. Always report any signs of breakdown to the nurse.
Which of the following are associated with smoking? A. Pneumonia B. Heart attacks C. Vitamin C deficiency D. All of the above
D: The effects of smoking can cause many diseases and medical complications. Cigarette smoking is the most frequent cause of lung cancer, and it also causes other lung conditions such as chronic obstructive pulmonary disease (COPD), emphysema, and pneumonia. Furthermore, smokers are more likely to develop heart disease and have heart attacks and strokes. Vitamins are depleted in smokers, especially vitamin C and the B vitamins.
Mrs. Shumway has an order for I&O. You have picked up her breakfast and note that she drank half of a 6 oz. glass of juice, 4 oz. of milk, and 8 oz. of coffee. Therefore, you document A. 240 cc. B. 685 cc. C. 920 cc. D. 450 cc.
D: The question involves HALF of a 6 oz. glass. 15 oz. = 450 cc. When converting ounces (oz.) to cubic centimeters (cc), remember that 1 oz. = 30 cc. Although an ounce is very slightly less, the amounts are considered equal by doctors and pharmacists. Also, 1 cc = 1 ml.
