cna headmasters exam practice set 1

The nurse has delegated the following order to you: obtain a urinary specimen to test for sugar and ketones in a client with a medical history of diabetes mellitus. You are aware that you will obtain the specimen: A. At bedtime B. 30 minutes after meals and at bedtime C. 30 minutes before meals and at bedtime D. Before breakfast

30 minutes before meals and at bedtime In diabetes, some sugar appears in the urine (glucosuria or glycosuria). The diabetic person may also have acetone (ketone bodies, ketones) in the urine. To determine the presence of these substances in the urine, these tests are usually done four times a day - 30 minutes before meals and at bedtime. The doctor uses the test to make drug and diet decisions. Double-voided specimens are best for these tests.

Which of the following is an example of a pulse rate that should be reported to the nurse? A. 45. B. 82. C. 64. D. 98.

A. 45 Any pulse outside the range of 60 to 100 should be reported immediately to the nurse for the resident's safety.

The following information is recorded on an intake and output record: milk 180 ml; orange juice, 60 ml; 1 serving scrambled eggs; 1 slice toast; 1 can Ensure oral nutritional supplement, 240 ml; 50 ml water after twice daily medications. Medications as given by the nurse at 9:00 AM and 9:00 PM. What is the client's total intake for the 7:00 AM to 3:00 PM shift? A. 530 ml B. 550 ml C. 580 ml D. 590 ml

A. 530 ml 180 + 60 + 240 + 50 = 530 ml

When recording data on a legal form, it is considered correct to write with which of the following? A. A black or a blue pen. B. A blue pen. C. A black pen. D. A red pen.

A. A black or a blue pen. Legal documentation must be composed with a black or a blue pen in order to be valid.

MRSA is an example of which of the following? A. A resistant strain of bacteria that is difficult to treat with antibiotics. B. A bacterial strain that is easy to treat with antibiotics. C. A mnemonic to remember how to act if there is a fire in the facility. D. A set of activity guidelines designed to keep residents safe.

A. A resistant strain of bacteria that is difficult to treat with antibiotics. MRSA stands for methacillinn-resistant Staphylococcus aureus and is very resistant to most antibiotic treatments.

The nursing assistant assigned to obtain vital signs for a group of residents omits taking the vital signs of one of the residents. When the nurse inquires as to the resident's missing vital signs, the nursing assistant admits to forgetting the resident. This is an example of which of the following? A. Accountability B. Flexibility C. Dependability D. Respectability

A. Accountability This is an example of accountability, even when admitting that you did not properly carry out your duties. Flexibility is your ability to adapt to the situation. Dependability is a basic expectation set by your employer, and the nursing assistant demonstrates this by his or her commitment to the job and to the residents. Responsibility is the ability to fulfill duties and expectations in your role as a nursing assistant.

The nursing assistant helps a patient who recently had a right-sided stroke to bathe. Which of the following describes the BEST method to support the patient's independence? A. Allow the patient to perform as much of the bath as possible. B. Ask the patient what he wants to do. C. Complete the entire bath for him to conserve his energy. D. Encourage the patient to do the best he can to clean himself.

A. Allow the patient to perform as much of the bath as possible. It is best for the patient to perform as much of the bath as possible, with the nursing assistant helping out when necessary.

Which of the following types of grief is considered a normal and healthy part of grieving? A. Anticipatory B. Complicated C. Unresolved D. Inhibited

A. Anticipatory Anticipatory grief occurs before the loss actually happens and is a normal part of grieving. Complicated, unresolved, and inhibited grieving indicate there is a problem with recovering from the loss.

A client has a deep vein thrombosis (DVT) and has orders by the doctor to apply elastic stockings. The nursing assistant is correct in performing this when she: A. applies the stockings while the client is on bed. B. applies the stockings while the client is sitting on the chair. C. applies the stockings while the client is sitting on the bed and dangles her feet. D. applies the stockings while the client is standing.

A. Applies the stockings while the client is on bed Elastic stockings or anti-embolic stockings are applied before the client gets out of bed. Otherwise the legs can swell from sitting or standing. Stockings are hard to put on when the legs are swollen. The client lies in bed while they are off. This prevents the legs from swelling.

The nursing assistant is helping residents to eat in the dining room when, suddenly, a resident stands from their seat and begins clutching their throat while coughing silently. The nursing assistant performs which of the following actions first? A. Ask the resident if they are choking. B. Begin CPR immediately. C. Call 911. D. Begin the Heimlich maneuver.

A. Ask the resident if they are choking. It is important to first assess whether or not the resident is choking. If they are able to answer, air is still moving through the trachea. If they nod yes, but are unable to speak, it is time to begin the Heimlich maneuver. The Heimlich should not be performed on anyone who is able to cough or speak.

As you assist a Hispanic client during her meal time, which food selections do you expect to be incorporated into a diet that would represent culturally sensitive care? A. Beans and tortillas. B. Cheese and olive oils. C. Vegetables and rice. D. Red meat and potatoes.

A. Beans and tortillas. Food preferences for Hispanic clients often include beans and tortillas. These foods are a staple in the Hispanic diet.

A patient with a respiratory illness complains of thick, sticky secretions that are hard to cough up. The nursing assistant knows to suggest which of the following? A. Drink plenty of fluids. B. Turn and cough every hour. C. Go outside and breathe the fresh air. D. Cough harder.

A. Drink plenty of fluids. Drinking fluids will help to lubricate the secretions so that the patient can cough them up easier.

The nursing assistant cares for a diabetic client. Which of the following symptoms in this client should be immediately reported? A. Emesis. B. Refusal to eat dessert. C. A cough. D. A bowel movement.

A. Emesis. Emesis (vomiting) in the diabetic client can indicate a potential for blood sugar imbalance. This should be reported to the nurse for further assessment.

Which of the following is an example of nonverbal communication? A. Hand gestures. B. A whisper. C. Mouthing words. D. Minimizing facial expression.

A. Hand gestures. Hand gestures are an example of nonverbal communication

The nursing assistant cares for a patient with hepatitis C. The nursing assistant knows that the patient could have come in contact with this disease in which of the following ways? A. IV drug use. B. Dirty toilet seat. C. Dirty eating utensils. D. Going barefoot.

A. IV drug use. IV drug use is one of the many ways that it is possible to contract the hepatitis C virus.

Which of the following pieces of assistive equipment would be most helpful in moving an immobile client from their bed to a chair? A. Mechanical lift B. Draw sheet C. Gait belt D. Wrist restraints

A. Mechanical lift A mechanical lift should be used for immobile or NWB residents. A gait belt should never be used on an immobile resident to lift them and should be used on individuals who are FWB or PWB.

Justine (CNA) was instructed by the stuff nurse to elevate the client casted left limb to prevent swelling. Justine is elevating the casted extremely correctly when she does which of the following? A Places the casted limb above the level of the heart. B Places the casted limb close to the body. C Places the casted limb below the level of the heart. D Places the casted limb at the level of the heart.

A. Places the casted limb above the level of the heart To reduce swelling, place the casted limb above the level of the heart with the use of pillows. Placing it below or at the level of the heart won't reduce swelling. To elevate a cast, the limb may need to be extended from the body.

During a bath, the three most important things for the resident are: A. Safety, security, and privacy. B. Safety, warmth, and cleanliness. C. Comfort, rest, and security. D. Privacy, rest, and warmth.

A. Safety, security, and privacy. Safety, security, and privacy are most important to the resident during a bed bath.

A patient who has recently been paralyzed below the waist due to a motorcycle accident refuses his medications from the nurse. The patient then refuses to say anything. What is the nursing assistant's best response? A. Say, "You seem upset." B. Ignore the client's temper tantrum. C. Say, "Why did you refuse your medication?" D. Say, "Don't worry, things will seem better tomorrow."

A. Say, "You seem upset." Reflective statements are an important therapeutic tool.

Before shaving a resident, the nursing assistant checks for which of the following items in the resident's care plan? A. Shaving instructions related to problems or issues clotting. B. History of a heart condition. C. Presence of the resident's razor from home. D.Any previous refusal of ADLs.

A. Shaving instructions related to problems or issues clotting It is necessary to check the shaving instructions in the resident's plan of care to be aware of any problems clotting and the necessity of using an electric razor as opposed to a traditional one.

A resident is having difficulty chewing regular meals at dinner. Which of the following diets might be suggested to order for next time? A. Soft. B. Liquid. C. Pureed. D. Hard.

A. Soft. A soft diet should be tried before a pureed diet for this patient.

Which of the following is not included in the care of clients with a pacemaker? A. The client is not allowed to be around electrical appliances. B. The client can operate a microwave. C. The client should avoid magnetic wands in airports. D. Cellular phone use should be monitored closely.

A. The client is not allowed to be around electrical appliances. Clients with a pacemaker can use electrical appliances. Microwaves are allowed, but caution must be used in airports to avoid the magnetic wands used for detection. Some clients have difficulties being around lawn mowers and cellular phones.

The nursing assistant takes the temperature of an elderly client and finds it to be 100.6 degrees F. The client reports having just taken a sip of hot tea. Which of the following actions is appropriate? A. The nursing assistants waits at least 15 minutes before retaking the temperature. B. The nursing assistant records the temperature in the chart. C. The nursing assistant scolds the client for not letting her know beforehand. D. The nursing assistant takes an axillary temperature instead.

A. The nursing assistant waits at least 15 minutes before retaking the temperature. Waiting fifteen minutes ensures the temperature of the mouth will be more accurate. Axillary temperatures in the elderly are often not the best measure.

It would be inappropriate to utilize an alcohol-based hand sanitizer in which of the following situations? A. The nursing assistant's hands are visibly soiled. B. The nursing assistant has just left the patient's room. C. The nursing assistant is about to enter the patient's room. D. The nursing assistant helps a patient to the bathroom while wearing gloves.

A. The nursing assistant's hands are visibly soiled. Visibly soiled hands require scrubbing, soap, and water to clean.

The nursing assistant prepares to give a patient a bed bath. Before turning the patient to rub their back, the nursing assistant notices that he has a Foley catheter in place. Where should the nursing assistant secure the catheter to ensure it is not pulled during the bath? A. To the lateral aspect of the patient's thigh. B. To the bed sheet. C. To the medial aspect of the patient's thigh. D. To the bed.

A. To the lateral aspect of the patient's thigh. Securing the catheter to the lateral aspect of the patient's thigh ensures it cannot be painfully pulled during the bath.

A nursing assistant begins caring for a client during a bed bath and notes he has a reddened, intact area on his coccyx. Which of the following correctly describes this condition? A. Ulceration stage 1. B. Ulceration stage 2. C. Ulceration stage 3. D. Ulceration stage 4.

A. Ulceration stage 1. This is a stage 1 ulceration, or bed sore, and should be reported to the nurse.

During a nursing assistant's orientation to the home facility, the nurse supervisor emphasizes that health team members communicate with each other to give coordinated and effective care to their clients. To communicate, the nursing assistant should do all of the following except: A. Use terms with many meanings. B. Be brief and concise. C. Present information logically and in sequence. D. Give facts and be specific.

A. Use terms with many meanings For good communication, the nurse aid should use words that mean the same thing to the sender and the receiver. Avoid words with more than one meaning.

Which of the following techniques would you use when interviewing a 94-year-old patient? A. Using a low-pitched voice. B. Enunciating each word slowly. C. Varying voice intonations. D. Reinforcing the words with pictures.

A. Using a low-pitched voice. the question does not present a client with hearing impairment. Elderly persons, with no underlying hearing problems, are sensitive to sound and can hear normally. By using a low-pitched voice, you will be able to convey your messages clearly to the client instead of shouting.

The nursing assistant should tell the nurse if the client with diabetes A. does not touch their lunch tray. B. decides not to finalize a will. C. reports numbness in their feet sometimes. D. combs their hair without being prompted.

A. does not touch their lunch tray. Someone with diabetes should always eat regular meals to keep their blood sugar relatively stable. Numbness in the feet is neuropathy, a common side effect of diabetes.

A patient is undergoing bowel training. The nursing assistant knows that bowel training: A. is used for people with colostomies to ensure a regular pattern. B. is a normal part of a healthy digestive tract. C. is a technique for going to the bathroom without pushing. D. is not used anymore.

A. is used for people with colostomies to ensure a regular pattern. Bowel training is used with ostomy patients to ensure a regular elimination pattern.

A client with a Foley catheter is ordered to ambulate twice daily. Before ambulating the client, the nursing assistant should: A. keep the bag below the bladder level. B. raise the bag above the bladder level. C. have the patient cover the bag with a pillow sleeve. D. ask the nurse to confirm this order.

A. keep the bag below the bladder level. Keeping the bag below the level of the cavity ensures that bacteria cannot migrate up from the bag and up into the bladder due to gravity.

The range of motion term "abduction" means: A. moving the extremity away from the body. B. moving the extremity toward the body. C. moving the extremity above the body. D. moving the extremity below the body.

A. moving the extremity away from the body. To abduct is to move away, to adduct is to move closer or toward.

The nursing assistant is aware that the purpose of the elastic stockings is to: A. prevent blood clots. B. hold dressings in place. C. reduce swelling after injury. D. prevent pressure sores.

A. prevent blood clots. Elastic stockings exert pressure on the veins. The pressure promotes venous blood flow to the heart. By doing so, the stockings prevent blood clots.

Before assisting the nurse to administer an enema to a bedridden client, the nursing assistant should most importantly: A. review the procedure and what's going to happen. B. open the window. C. reassure the client that it won't hurt much. D. gather all materials needed.

A. review the procedure and what's going to happen. It is important for the resident to know what's going to happen and what to expect.

A nursing assistant who suspects a resident is being abused by someone in the facility should report it to: A. the charge nurse. B. the nurse caring for the client. C. a fellow nurse's aide. D. the CEO.

A. the charge nurse. Reporting it to the charge nurse will ensure that it is handled properly.

A client in the day room is having a panic attack. The nursing assistant should: A.tell the client to breathe as slowly and deeply as possible. B. have the client talk about the panic attack. C. encourage the client to verbalize their feelings. D. ask the client about the cause of the panic attack.

A.tell the client to breathe as slowly and deeply as possible During a panic attack, the nursing assistant should make the client comfortable and encourage them to breathe slowly and deeply. Asking them to count backwards slowly from 100 can also be helpful. During an attack, the client is unable to talk about anxious situations and isn't able to address uncomfortable feelings and frustrations. While having a panic attack, the client is also unable to focus on anything other than the symptoms, so the client won't be able to discuss the cause of the attack.

A patient has just received news about the death of his spouse. He states to the nursing assistant, "I can't believe this has happened to me. I don't know what to do. How can I live without my wife?" The nursing assistant best responds by stating: A. "You will need more time to cope with this loss." B. "I understand you're in pain. I'll stay with you." C. "This kind of thing will happen to everyone eventually." D. "Do you and your wife have any children together?"

B. "I understand you're in pain. I'll stay with you." This is the best answer because it reflects what the patient is feeling (pain) and stays with the patient to comfort him.

A client at the facility receives a new roommate. While the roommate is in the bathroom, the clients leans toward the nurse and whispers, "Why is she here anyway? Is she sick?" The best response by the nursing assistant is A. "Why don't you ask her yourself?" B. "I'm afraid I can't share that information with you." C. "She's here for the same thing as you!" D. "I'm not sure. Let me take a look at her chart."

B. "I'm afraid I can't share that information with you." HIPPA requires you to keep client's health information confidential. Period.

A nursing assistant happens to witness a patient fall and is asked to document what happened. Which of the following statements is written correctly for legal documentation? A. "The patient tripped over bedsheets because housekeeping left them on the floor all day." B. "The patient slipped and slid down the side of the bed to the floor, landing on their sacrum." C. "The patient fell because they ignored me when I told them to stay in bed." D. "The patient fell because the nurse forgot to lock the wheels of the bed again."

B. "The patient slipped and slid down the side of the bed to the floor, landing on their sacrum." This statement is the only correct documentation because it reflects events as they happened and does not assign blame.

On nursing rounds, a client is found lying on the floor. Which statement would be most appropriate for the nurse aide to record in the client's medical record? A. "It is most likely that the client attempted to climb over the side rails and fell." B. "Upon entering the room, the client was found lying on the floor." C. "The client had been restless all evening and was trying to get out of bed." D. "The presence of a bed alarm could have prevented the fall."

B. "Upon entering the room, the client was found lying on the floor." The nurse aide should document only the facts of the situation. Based on the scenario, the cause of the fall was not identified. Thus the facts for documentation are that the client was found lying on the floor upon entering the room.

Which of the following residents is demonstrating orthopneic position? A. A resident sits in a chair with their back straight. B. A resident sits on the side of the bed and leans forward over a bedside table. C. A resident walks using a cane. D. A resident lays on their stomach with their face to the side.

B. A resident sits on the side of the bed and leans forward over a bedside table. Orthopneic position is meant to assist in breathing. Leaning forward makes it easier to get air into the lungs.

The abbreviation Rx indicates: A. A type of wound. B. A treatment. C. An acute illness. D. A disease.

B. A treatment. The abbreviation Rx stands for 'treatment' or 'prescription.'

The nursing assistant knows that the responsibilities of the position do NOT include? A. Helping a resident to bathe. B. Administering a medication. C. Keeping a resident's room tidy. D. Applying an icepack as ordered.

B. Administering a medication. Nursing assistants may not administer medications, it is not within their scope of practice. Only RNs, LPNs, and other properly licensed personnel may give medications.

To prevent circulatory impairment in an arm when applying an elastic bandage, which of the following methods is best? A. Wrap the bandage around the arm loosely. B. Apply the bandage while stretching it slightly. C. Apply heavy pressure with each turn of the bandage. D. Start applying the bandage at the upper arm and work toward the lower arm.

B. Apply the bandage while stretching it slightly. Stretching the bandage slightly maintains uniform tension on the bandage. Wrapping the bandage loosely wouldn't secure the bandage on the arm. Using heavy pressure would cause circulatory impairment. Beginning the wrapping at the upper arm would cause uneven application of the bandage. For example, elastic stockings are applied distal to proximal to promote venous return.

Your client has had a bowel movement. The stool is black in color and has a tarry consistency. What is your next action? A. Ask the client what her previous meal contained. B. Ask the nurse to observe the stool. C. Dispose of the stool and report the color to the nurse. D. Ask a co-worker if this is normal for this client.

B. Ask the nurse to observe the stool. The nurse aide should report to the nurse any abnormal stools. Carefully observe the color, amount, consistency, odor, shape, size, frequency of defecation, and complaints of pain.

The nurse inserts a Foley catheter to relieve a client urinary retention. Which of the following is an inappropriate action in caring for client with an indwelling catheter? A. Emptying the drainage bag every 6-8 hours. B. Attaching the drainage bag to the lowest part of the siderails near the client's feet. C. Keeping the drainage bag below bladder level. D. Positioning the tubing without dependent loops.

B. Attaching the drainage bag to the lowest part of the side rails near the client feet The bag hangs from the bed frame, chair, or wheel chair. It must not touch the floor. The bag is always kept lower than the client's bladder. If the drainage bag is higher than the bladder, urine can flow back into the bladder and an infection can occur. Therefore, do not hang the drainage bag on a bed rail. When the bed rail is raised, the bag is higher than the bladder level. When the person walks, the bag is held lower than the bladder. Emptying of the drainage should be done every 6-8 hours to prevent proliferation of microbes which can develop into infection. The tubing should not have dependent loops to prevent stasis of urine in the tubes which can promote backflow to the bladder.

A client with a terminal illness tells the nurse that he has begun praying every night. The client states, "If I pray every night, God will forgive me." This represents which stage of grief? A. Acceptance B. Bargaining C. Denial D. Anger

B. Bargaining This patient is bargaining to be "forgiven" in order to cure his illness. This is a normal stage in the grieving process

In preparing a client for a hot Sitz bath, the nursing assistant should check the temperature of the water. The ideal water temperature is: A.Between 105°F and 120°F B. Between 95°F and 110°F C. Between 80°F and 93°F D. Between 65°F and 80°F

B. Between 95F and 110F The ideal temperature of the water for a hot Sitz bath is between 95°F and 110°F. Water that is too hot will burn the client, and water that is too cold will cause the muscles to tighten up rather than relax. A hot Sitz bath will provide relaxation and relieve muscle spasms, soften exudates, hasten the suppuration process, hasten healing (in cases of perianal surgeries), reduce congestion, and provide comfort in the perineal area.

Dyspnea is a term that refers to difficulty with which of the following? A..Urinating B.Breathing C.Defecating D.Swallowing

B. Breathing Dyspnea is a term that refers to difficulty with breathing.

A resident is choosing items for breakfast. Which of the following items contains the most amount of potassium? A. Eggs B. Cantaloupe C. Toast D. Strawberries

B. Cantaloupe Cantaloupe is a melon that contains massive amounts of potassium. Other foods that contain high potassium include bananas and dark leafy greens.

Elderly patient are prone to stomach-aches and bloating. Which of the following foods are avoided since they are gas-forming and contribute to the Said condition? A. Prunes B. Cauliflower C. Colas and sodas D. Protein rich foods

B. Cauliflower Cauliflower is gas-forming. Other examples of gas-forming foods are beans, cabbage, radishes, and cucumbers.

When applying a jacket restraint to a patient, it is most important to: A. Check that the patient is not able to hit any other patients nearby. B. Check that the patient can fully expand their chest for breathing. C. Use a half-bow knot to secure each tie around the bed frame. D. Use a square knot to fasten the vest ties together behind the chair.

B. Check that the patient can fully expand their chest for breathing Breathing is always priority number one for patients. After that, concentrate on how to apply the vest properly.

The client asks the nursing assistant to assist her to cut her toenails. The nursing assistant knows this client has type two diabetes. Which of the following actions is best? A. Check the client's blood glucose before cutting her toe nails. B. Check the chart for physician orders regarding nail trimming. C. Report to the nurse that the client needs her toenails trimmed. D. Retrieve a safety clipper and hand it to the client.

B. Check the chart for physician orders regarding nail trimming. Diabetic clients often have special instructions regarding nail trimming. Check the chart for specific orders.

A nursing assistant will be changing the soiled bed linens of a client with a draining pressure ulcer. Which of the following protective equipment should the nursing assistant wear? A. Mask B. Clean gloves C. Sterile gloves D. Shoe protectors

B. Clean gloves Clean gloves protect the hands and wrists from microorganisms in the linens. Sterile gloves allow one to touch a sterile object or area without contaminating it. A mask protects the wearer and client from droplet nuclei and large particle aerosols. Shoe protectors prevent static and microorganism transmission from the floor of one room to another.

A nursing assistant is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls on the intercom to relay that there is an emergency phone call. The appropriate action is to: A. Immediately walk out of the client's room and answer the phone call. B. Cover the client, place the call light within reach, and answer the phone call. C. Finish the bed bath before answering the phone call. D. Leave the client's door open so the client can be monitored and the nurse aide can answer the phone call.

B. Cover the client, place the call light within reach, and answer the phone call. Because the telephone call is an emergency, the nurse aide may need to answer it. The other appropriate action is to ask another nurse aide on staff to accept the call. However, that is not one of the options given on this question. To maintain privacy and safety, the nurse aide covers the client and places the call light within the client's reach. Additionally, the client's door should be closed or the room curtains pulled around the bathing area.

To obtain a 24-hour urine specimen, the nurse assistant should: A. Collect each voiding in separate containers for the next 24 hours. B. Discard the first voided specimen and then collect the total volume of each voiding in 24 hours. C. For the next 24 hours, retain a 30ml specimen of each voiding after recording the amount voided. D. Keep a record of the time and amount of each voiding for 24 hours.

B. Discard the first voided specimen and then collect the total volume of each voiding in 24 hours. A 24-hour urine specimen is a collection of all urine by a client over a 24-hour period. All urine is collected for 24 hours, usually from 7 A.M. on the first day to 7 A.M. the following day. It is necessary to ask the client to void, and then discard this voided urine. This is done because this urine has been in the bladder an unknown length of time. The test should begin with the bladder empty. For the next 24 hours, save all the urine voided by the client in one collection bottle. Recording the amount of urine and the time voided is not important in this procedure.

When assisting the resident to transfer from the bed to a chair, the nursing assistant knows it is necessary to do all of the following EXCEPT: A. Assist the resident to put on a robe and nonskid slippers. B. Encourage the resident to pivot themselves with minimal assistance. C. Place the chair on the resident's strong side. D. Place the bed in the lowest position and lock the wheels.

B. Encourage the resident to pivot themselves with minimal assistance. Residents should be fully assisted and supervised when turning in order to prevent falls.

Which of the following actions is correct when giving a client a bath? A. Clean the perineal area by gently wiping with the washcloth from back to front. B. Ensure any areas not being currently washed are covered by a sheet or towel. C. Make the client give themselves their own bath, even if they perform it poorly. D. Lotion the client's feet after bathing and be sure to get in between the toes.

B. Ensure any areas not being currently washed are covered by a sheet or towel. In order to maintain privacy and keep a client warm, it is important to cover areas that are not being bathed. When cleaning the perineal area, wipe front to back. Have the client assist with ADLs, but support them. Do not lotion between toes because it predisposes them to fungal infections.

The nursing assistant walks into a patient's room and discovers him masturbating. Which of the following actions is correct? A. Scold the patient and tell him he should be ashamed of himself. B. Exit the room to provide privacy for the patient. C. Report the activity to the nurse in charge. D. Ask the patient why he is doing this to himself.

B. Exit the room to provide privacy for the patient Masturbation is a normal expression of sexual health. Attempt to exit quietly without disturbing the client in order to preserve his privacy and decency.

Which of the following is the leading cause of accidental death in those 85 years of age and older? A. Poisoning. B. Falls. C. Car accidents. D. Drowning.

B. Falls. Falls are the number one cause of accidental death in this age group. Work hard to prevent them!

A nursing assistant cares for a resident who has a cast on the left arm. While receiving a bed bath, the nursing assistant notices that the fingers on the client's left hand are cold. Which of the following actions should the nursing assistant take next? A. Tell the nurse immediately. B. Feel the client's fingers on the other hand. C. Ask the client if it hurts. D. Give the client gloves.

B. Feel the client's fingers on the other hand First, check the fingers on the other hand. The client may have overall decreased circulation. If the fingers on the other hand are warm, however, the cast may need to be adjusted.

A client with a hearing impairment is admitted to a busy hospital unit. Which intervention is most appropriate to meet the client's needs while preventing sensory overload? A. Allow all the client's family members to stay with the client. B. Have conversation at the bedside directed to the client. C. Keep the television or radio on for the client continuously. D. Keep the overhead light on at all times.

B. Have conversation at the bedside directed to the client. Having the conversation directed to the client meets the client's needs while creating less disturbances. This will help decrease overstimulation, especially for the client who is hearing impaired. Lights in the room should be dimmed to reduce visual overload. Having too many family members with the client will only add to the already sensory-overloaded client.

The Omnibus Budget and Reconciliation Act (OBRA) requires all nursing homes to do what for their clients? A. Help residents write wills and choose power of attorneys. B. Help residents reach their highest level of psychological and mental functioning. C. Help residents perform ADLs and avoid neglect. D. Help residents to transfer to other nursing homes if they want.

B. Help residents reach their highest level of psychological and mental functioning. OBRA requires facilities to help their residents achieve their highest points of physical, psychological, and mental functioning, as well as make choices about their lives.

When a client constantly ignores the urge to void, the client is putting themselves in danger of what complication? A. Constipation B. Incontinence C. Insomnia D. Poor appetite

B. Incontinence Incontinence can occur if the bladder becomes too full and is unrelieved.

Which of the following procedures cannot be performed by a nursing assistant? A. Reporting a soiled dressing to the nurse. B. Inserting a Foley catheter. C. Performing oral care on an unconscious patient. D. Assisting the client to the bathroom.

B. Inserting a Foley catheter. Inserting an indwelling urinary catheter requires sterile technique, which is not a component of nursing assistant skills.

The nursing assistant assigned to the medical ward receives a new client for the shift. She wants to know about the case of the client and the kind of nursing care and therapeutic management already done to help the client's condition throughout her stay at the hospital. The nursing assistant therefore reads the: A. Flow sheet B. Kardex C. Progress notes D. Nursing discharge summary

B. Kardex The Kardex is a widely used, concise method of organizing and recording data about a client, making information quickly accessible to all members of the health care team. The Kardex reveals specific data about the client, including therapeutic management done and nursing care. A flow sheet enables nurses to record nursing data quickly and concisely to provide an easy-to-read record of the client's condition over time. Progress notes provide information about the progress a client is making. Lastly, the nursing discharge summary is completed only when the client is being discharged.

Which of the following diseases does not require airborne precautions? A. Measles. B. MRSA. C. Tuberculosis. D. Chickenpox.

B. MRSA. MRSA is a disease transmitted by skin-to-skin contact. It does not require airborne or droplet precautions.

A divorced 33-year-old former drug addict, is paralyzed from the waist down. During hospitalization, no family ties are evident; however, he reportedly has two teenage sons. How might you assist him in meeting his needs as they related to roles and relationships? A. Have get-well cards sent anonymously. B. Provide paper and pen for letter writing to his sons. C.Spend time with him after work hours. D. Leave him alone to allow for meditation.

B. Provide paper and pen for letter writing to his sons. In helping this client, the nursing aide can provide assistance by providing paper and pen for letter writing to his sons. Based on the scenario, the client has concerns for his love and belonging needs and these should not be neglected. The nursing aide can then give the letters to the nurse for evaluation/screening and proper mailing if appropriate.

Which of the following pulses will be most commonly used by a nursing assistant when acquiring vital signs? A. Popliteal. B. Radial. C. Brachial. D. Femoral.

B. Radial. The radial pulse is the most easily accessible location to take a pulse.

A nursing assistant arrives at work. Three hours into the shift, she feels chilled and takes her temperature. The read-out is 101.0 degrees F. The correct action is to: A. Continue working, but wear a mask. B. Report herself to the nursing supervisor and be dismissed home. C. Continue working, but wash hands every fifteen minutes. D. Leave immediately for home.

B. Report herself to the nursing supervisor and be dismissed home. As a nursing assistant, you can't just leave your patients without transferring their care elsewhere. The nursing supervisor can assist with this process if you are too sick to do so yourself. A fever means that you are an infection risk to residents.

A nursing assistant takes the blood pressure of a client and finds it to be 82/43. The client reports feeling dizzy. The nursing assistant should: A. take the client's pulse next. B. report the finding to the nurse. C. record the vital sign in the chart. D. instruct the client to drink more fluids.

B. Report the finding to the nurse. It is very important to report a symptomatic low blood pressure to the nurse for further investigation.

The nursing assistant suspects that a resident in the facility is being abused due to multiple unexplained bruises, refusal to answer most questions, and refusal of ADLs. Which of the following actions should the nursing assistant take next? A. Notify the nurse assigned to care for the patient about the bruises. B. Report the suspected situation to the nursing assistant's immediate supervisor. C. Ask the resident repeatedly to identify an abuser. D. Wait for more proof in order to identify the abuser.

B. Report the suspected situation to the nursing assistant's immediate supervisor. Abuse in nursing facilities, or even suspicion of abuse, should be reported immediately to the nursing assistant's supervisor. This requires more intervention than the nursing assistant's scope of practice covers. Waiting or notifying the nurse only about bruises may delay getting the resident help.

A client has an indwelling urinary catheter, and urine is leaking from a hole in the collection bag. Which of the following actions would be most appropriate? A. Cover the hole with tape. B. Report to the nurse immediately. C. Disconnect the drainage bag from the catheter and replace it with a new bag. D. Place a towel under the bag to prevent spillage of urine on the floor, which could cause the client to slip and fall.

B. Report to the nurse immediately. The system is no longer a closed system and bacteria might have been introduced; the nursing assistant should report to the nurse immediately for the removal of the catheter and inserting a new one using sterile technique. Placing a towel under the bag and taping up the hole leave the system open, which increases the risk for infection. Replacing the drainage bag is not recommended due to the limitations of the duties of the nursing assistant and the increased risk of infection.

Clients requiring oxygen therapy should be monitored for hypoxia. Early signs for hypoxia include: A. Breathing comfortably only when sitting. B. Restlessness, dizziness, and disorientation. C. Cyanosis and increased pulse rate. D. Increased temperature and decreased respiratory rate.

B. Restlessness, dizziness, and disorientation. Hypoxia means that the cells do not have enough oxygen. It is a life-threatening condition. The brain is very sensitive to inadequate oxygen. Restlessness is an early sign, as are dizziness and disorientation. Hypoxia will have increased respiratory rate, increased pulse rate, but not increased temperature. Cyanosis, or bluish discoloration of the skin, is a late sign of hypoxia.

Protective devices are often used to prevent and treat pressure ulcers and skin breakdown. Which of the following devices is least likely used for this particular purpose? A. Trochanter rolls B. Rubber sheet C. Bed cradle D. Flotation pads

B. Rubber sheet A rubber sheet protects the client from soiled linens and excess drainage. It can even predispose the client to develop skin breakdown and pressure ulcers because it creates moisture and friction to the skin. Trochanter rolls are applied to prevent the hips and legs from turning outward and aids in proper positioning of the client. A bed cradle is placed on bed and over the person. Top linens are brought over the cradle to prevent pressure on the legs and feet.

Another term that is similar to the word convulsion is: A. Tremors. B. Seizure. C. Fever. D. Hypertension.

B. Seizure. Convulsions are also sometimes known as seizures.

Which action by a nurse aide could jeopardize the confidentiality of computerized medical records available at a nurse's station? A. Log out and sign off all computer screens before leaving a terminal. B. Share passwords for computer access with colleagues who have forgotten their own passwords. C. Periodically change computer access passwords. D. Prevent an unidentified healthcare worker from viewing computer records.

B. Share passwords for computer access with colleagues who have forgotten their own passwords. The nurse aide should never share computer access passwords with other colleagues, as another person could then use the nurse aide's personal identifier to compromise a client's confidentiality. The confidentiality of computerized medical records must be maintained.

Which of the following guidelines regarding residents who are hard of hearing would be considered correct? A. Encourage family participation to make sure they understand you. B. Speak clearly and slowly as you face the resident. C. Write down words rather than speaking .D. Speak in a high-pitched voice to enhance understanding.

B. Speak clearly and slowly as you face the resident.

"Log-rolling" is a technique best used for which of the following patient diagnoses? A.Left tibial fracture. B. Spinal cord injury (SCI). C. Cellulitis of the right arm. D. Psychosis

B. Spinal cord injury (SCI) A SCI patient is prone to further damage and injury to the spinal cord if the legs cross over the midline (in a twisting motion). This can be avoided with proper log-rolling technique.

Of the following symptoms, which one is most likely due to an infection in a resident? A. Pale skin. B. Sudden onset confusion C. Tented skin. D. Aphasia.

B. Sudden onset confusion Infection, especially in older clients, tends to cause sudden onset confusion. Tented skin may be normal for an older client, as could pale skin. Aphasia could indicate the onset of a stoke.

An eighty-five year-old resident at a longterm care facility is signing up for an afternoon activity. The resident asks the nursing assistant which choice she thinks is best. Which of the following should the nursing assistant suggest? A. Gardening. B. Tai chi and meditation. C. Basketball. D. Watching TV.

B. Tai chi and meditation. Tai chi is excellent for balance and would help the patient to decrease her risk of falls. Meditation may increase happiness and decrease any depression. Watching TV encourages stasis, not movement, and the rest are perhaps too active.

A nursing assistant cares for a resident. Which of the following skin care measures are correct? A. The nursing assistant does not begin perineal care until a second staff member is present. B. The nursing assistant notes an unblanchable red area on the resident's sacrum and reports it to the nurse. C. The nursing assistant applies talcum powder beneath the abdominal folds of the resident. D. The nursing assistant applies a prescription ointment as ordered.

B. The nursing assistant notes an unblanchable red area on the resident's sacrum and reports it to the nurse. It is the duty of the nursing assistant to report any red pressure spots on the resident to the nurse. The nursing assistant may not apply any prescription ointments. Talcum powder is not recommended. A second staff member is not needed for perineal care.

While putting an elderly client with an indwelling urinary catheter in bed, a nursing assistant notices the tubing hanging below the bed. She places the tubing in a loop on the bed with the client and makes sure the client won't lie on the tubing. Which of the following rationales explains the nursing assistant's action? A. To inhibit drainage. B. To allow drainage to occur. C. To allow the urine to collect in the tubing. D. To have the client check the tubing for urine.

B. To allow drainage to occur. Catheter tubing shouldn't be allowed to develop dependent loops or kinks because this inhibits proper drainage by requiring the urine to travel against gravity to empty into the bag. Permitting the urine to collect in the tubing increases the risk of infection. Observing the catheter and tubing is the responsibility of nursing staff, not the client.

Monique stopped working as a nursing assistant when she gave birth to her daughter. After 2 years of being a full-time wife and mother, she now decides to go back to work to help pay bills. What are the requirements that Monique has to comply with before going back to work again? A. Enroll in a refresher course. B. Undergo a retraining and a new competency evaluation. C. Competency evaluation only. D. No other requirements are required. Just present letter of intent to the Board to go back to work.

B. Undergo a retraining and a new competency evaluation. Retraining and a new competency evaluation program are required for nursing assistants who have not worked for 2 consecutive years (24 months). It does not matter how long you worked as a nursing assistant. What matters is how long you did not work.

Clients and families have the right to receive care that is: A. determined necessary by the health team. B. culturally acceptable to them. C. dictated as appropriate by medical research. D. technologically advanced and inexpensive.

B. culturally acceptable to them Clients and families are unique individuals and define their own systems of daily living, which reflect their values, motives, and lifestyles. Providing care for clients coming from ethnic, cultural, or religious backgrounds deserve to receive appropriate and acceptable health care. You must respect and accept the person's culture.

The nursing assistant is correctly providing penile hygiene to an unconscious clients if she: A. uses warm water without soap. B. dries all areas of the penis thoroughly. C. washes from the base of the shaft to the tip. D. avoids retracting the foreskin if not circumcised.

B. dries all areas of the penis thoroughly. Careful drying is essential to avoid maceration of the penis. To decrease the risk for infection, wash the penis from the tip the base to reduce the risk for introducing microorganisms into the urethral meatus. Effective cleaning requires soap and thorough rinsing. It's also essential to remove secretions that accumulate under the foreskin because they can lead to inflammation and are associated with the development of penile cancer. The foreskin of uncircumcised men must be retracted for cleaning, then replaced to prevent paraphimosis (capistration).

After applying an elastic bandage to a client's right leg, you need to check the color and temperature of the leg: A. every 15 minutes. B. every hour. C. every 2 hours. D. every shift.

B. every hour. In applying elastic bandage, expose fingers or toes to allow circulation checks. Check the color and temperature of the extremity every hour. If the person complains of pain, itching, tingling, or numbness, remove the bandage and tell the nurse at once.

A typical blood pressure around the upper arm should NOT be taken when the patient: A. complains that "this is the fifth time today." B. has IV catheters in both the left and right arms. C. has heart failure. D. has had lymph nodes removed around the axilla of the left arm.

B. has IV catheters in both the left and right arms. If the patient has IV catheters in both arms, a blood pressure cuff will impede their intravenous flow.

A resident comes out of their room saying they have burned their leg after they dropped hot soup on it. The skin looks blistered and red. The nurse assistant knows this is a: A. superficial burn B. partial thickness burn C. total thickness burn D. serious burn

B. partial thickness burn This describes a partial thickness burn. A total thickness burn appears waxy and white, while a superficial burn might be described as blotchiness of the skin with no blistering

A nursing assistant enters a client's room and finds a fire burning in a trashcan. The nursing assistant's first action is to: A. call the nurse for help. B. remove the patient. C. try to put out the fire. D. pull the fire alarm.

B. remove the patient. The acronym "RACE" is used for fire situations- Rescue, alarm, contain, extinguish. First you must rescue the client to prevent harm.

An asthmatic client can be relieved from dyspnea when he is placed in orthopneic position. This can done by: A. placing the head of bed in 90° angle. B. sitting up and leaning over a table with a pillow. C. hyper-extending the neck while on high back rest. D. placing the client on a high back rest using a pillow

B. sitting up and leaning over a table with a pillow. Clients with difficulty breathing often prefer sitting up and leaning over a table to breathe. This is called orthopneic position. Place a pillow on the table to increase the client's comfort.

The nursing assistant cares for a client who is extremely agitated. She yells, screams, and frequently tries to bite staff. The nursing assistant should: A. use restraints to ensure the client's safety. B. speak calmly in an authoritative and neutral manner to the client. C. use the television to distract the client. D. provide care only when absolutely necessary.

B. speak calmly in an authoritative and neutral manner to the client. Speaking calmly in a neutral manner can soothe an agitated client. Restraints are not appropriate for a client who is merely confused and can be placated.

A client with Alzheimers wakes up more confused than usual one morning. The nursing assistant knows that, after breakfast, it is most important to support normal gastrointestinal tract function by A. recording intake and output. B. taking the client to the bathroom. C. assisting the client to call family members. D. brushing the client's teeth.

B. taking the client to the bathroom. Taking the client to the bathroom will most likely prompt a bowel movement, which supports GI tract health. A confused patient may not remember what the urge means.

A client in the hospital announces that he is leaving this minute and that no one can stop him. The nursing assistant should: A. tell the patient to wait and see if he likes the care more as he feels better. B. tell the patient to wait so that she can get the nurse because he has to sign a form. C. warn the patient that it's better to follow the doctor's recommendations. D. tell the patient that he can't leave.

B. tell the patient to wait so that she can get the nurse because he has to sign a form Clients who want to leave AMA (against medical advice) may do so, but they need to sign an AMA form or their insurance will often not pay for treatment.

Rectal temperatures are usually taken on patients who are: A. combative. B. unconscious. C. anxious. D. confused.

B. unconscious. Unconscious patients cannot close their mouths around an oral thermometer. Any of the other patient types would be resistant and/or fearful to a rectal thermometer.

Proper body mechanics when lifting clients involve which of the following? A. Keep the spine curved. B. Bending at the waist. C .Bending at the knees. D. Avoid seeking assistance.

Bending at the knees. Bending at the knees is the only proper body mechanic listed. Avoid doing all the others!

Question 46 A 69-year-old client has been diagnosed with colon cancer. Upon the request of her daughters, the Powers of Attorneys, the information was withheld from her. When her daughters leave, the client asks you a question about her diagnosis. What will be your response to this situation? A. "I'm sorry, I don't know." B. "I'm sure it's nothing to worry about. You look fine to me." C. "I don't have any information as of the moment, but I'll find out for you." D. "You need to ask your doctor about that, not me."

C. "I don't have any information as of the moment, but I'll find out for you." The nursing assistant may spend more time with the client than any member of the health care team. Often, you are the only person a client will see all day. If this situation arises, it is best not to lie to the client. Do not tell him you do not know when you should be aware of the information. If you lie, the client may find out and never trust you again. It is no shame to say you do not have the information readily at hand. But if you say you do not know, you close the conversation. Tell the client you will find her an answer. Then call and talk to your supervisor. Plan an answer with her. When you promise to find an answer for a client, do it. Do not go back on your word.

A client in the long term facility tells the nursing assistant "I am too depressed to talk to you. Leave me alone." Which of the following response by the nursing assistant is most therapeutic? A. "I'll be back in an hour." B. "Why are you so depressed?" C. "I'll sit with you for a moment." D. "Call me when you feel like talking to me."

C. "I'll sit with you for a moment." Do not heed to the demand of the client that he does not want you around. Depressed clients often have thoughts of dying or committing suicide. It is best to assess the client this time for any suicidal ideations. Use silence and active listening when interacting with the client. Be comfortable sitting with the client in silence. Let the client know you are available to converse, but do not require the client to talk.

The nursing assistant is helping a male patient to use the urinal. She pulls the curtain around the bed for privacy before saying: A. "If you do not fill it completely, I will empty it later." B. "If you need any more assistance, please ring the bell." C. "Please ring me when you are finished and I will empty it for you." D. "Please let me know later how many mL."

C. "Please ring me when you are finished and I will empty it for you." The nursing assistant cannot ask the patient to measure his own urine, or delay in emptying it. Once the patient is finished, he should ring the bell so that she can measure it and empty it herself.

A client says to you "I am worthless person, I should be dead." What is the best response that you, the nursing assistant, can make? A. "Don't say you are worthless, you are not a worthless person." B. "We are going to help you with your feelings." C. "What makes you feel you're worthless?" D. "What you say is not true."

C. "What makes you feel you're worthless?" Clients with depression are often overwhelmed by the intensity of their emotions. Talking about these feelings can be beneficial. Initially, the nursing assistant encourages clients to describe in detail how they are feeling. Sharing the burden with another person can provide some relief. At these times, the nursing assistant can listen attentively, encourage clients, and validate the intensity of their experience. It is important at this point that the nursing assistant does not attempt to "fix" the client's difficulties or offer clichés. These remarks belittle the client's feelings or make the client feel more guilty and worthless.

Choose the observation that should be reported to the nurse STAT. A. Temperature of 98.9 degrees F. B. A pulse of 72. C. 32 respirations per minute. D. Blood pressure of 102 over 75.

C. 32 respirations per minute. The number of respirations is slightly too fast to be considered normal and could be considered a respiratory problem.

Which of the following best describes the concept of empathy? A. A nursing assistant asks a patient whether they would like to take a walk or watch a movie. B. A nursing assistant speaks with a dietician about alterations to the patient's meal tray. C. A nursing assistant speaks with a patient about their recent diagnosis of cancer. D. A nursing assistant asks the nurse when she may take a meal break.

C. A nursing assistant speaks with a patient about their recent diagnosis of cancer. Speaking with a patient about a recent, potentially devastating diagnosis, shows a willingness to discuss feelings and issues that may be difficult to talk about.

Range-of-motion exercises are most important for which type of patient to perform? A. A patient with a pulled leg muscle. B. A patient who has hypertension. C. A patient with hemiplegia. D. A patient with depression.

C. A patient with hemiplegia. he patient with hemiplegia should participate in range-of-motion exercises in order to maintain joint function and avoid blood clots. Hemiplegia is a form of paralysis that affects one side of the body, often just one arm and one leg, but at times extending partially to the torso.

Which is correct about ostomy care? A. It is done under sterile technique. B. It needs doctor's order for changing of ostomy pouches. C. Able clients can perform this procedure by themselves once they have been taught by the nurse. D. The client can still defecate normally.

C. Able client can perform this procedure by themselves once they have been taught by the nurse Ostomy care is done aseptically (rules of cleanliness). It does not require a doctor's order for changing the ostomy pouch. The collection bag must be changed when it is full or when the adhering seal is broken. A client with ostomy will have a change in the normal bowel movement. The fecal matter will be collected through an appliance that is held over the stoma by a special adhesive or paste.

Which of the following is a key part of care when administering a bath to a resident? A. Clean the perineal area of a patient before assisting them to clean their face. B. Use cool water when bathing the patient to promote better circulation. C. Allow participation in care to promote a sense of independence. D. Perform all care for the resident in order to conserve their energy.

C. Allow participation in care to promote a sense of independence. Allowing the resident to participate in care will raise their self esteem and allow autonomy. It is inappropriate to clean the perineal area before the face, or to use cool water rather than comfortably warm water

Rehabilitation care after any injury should begin when? A. When the patient enters a rehab program. B. One week into recovery. C. As soon as possible. D. When the doctor says so.

C. As soon as possible. Rehabilitation should begin as soon as possible in order to get the most recovery.

When caring for a dying client, the nurse aide should perform which of the following activities? A. Encourage the client to reach optimal death. B. Assist the client to perform activities of daily living. C. Assist client towards a peaceful death. D. Motivate client to gain independence.

C. Assist client towards a peaceful death Major goals for dying clients include maintaining physiologic and psychological comfort and achieving a dignified and peaceful death, which includes maintaining personal control and accepting their declining health status.

Which of the following most addresses a client's needs in regard to spirituality? A. Ask the client why he or she is of a particular faith. B. Provide the client with warm water, soap, and towels every morning. C.Assist the client to the facility's chapel every Sunday. D. Treat any religious objects in the client's room as if they were any other.

C. Assist the client to the facility's chapel every Sunday. Support the client in their own individual religious needs. Treat any religious objects in their room with respect.

When a terminally ill client assumes artificial cheerfulness and refuses to believe that loss is happening, what stage of grieving is he in? A. Bargaining B. Acceptance C. Denial D. Depression

C. Denial The client is in the stage of denial, the first stage of grieving, when he demonstrates artificial cheerfulness and refuses to believe that loss is happening. This indicates that the client is not ready to deal with the reality of the situation. Bargaining is the third stage wherein the client seeks to bargain to avoid loss. The client may express feeling of guilt or fear of punishment for past sins, real or imagined. Depression is the fourth stage wherein the client grieves over what has happened and what he cannot be. The client may talk freely or may withdraw from the people trying to make contact with him. Acceptance is the last stage of the grieving process wherein the client comes to terms with loss. The client may have decreased interest in surroundings and support persons. In addition, the client may wish to begin making plans.

Which of the following disorders are said to be irreversible? A. Chicken pox. B. Asthma. C. Emphysema. D. Hypertension.

C. Emphysema Emphysema is the only truly irreversible disease listed. Asthma may be "outgrown" after childhood, and chicken pox is an acute, short-lived illness. Hypertension may be "cured" with diet, exercise, and medication.

Diabetes is a disease of which primary body system? A. Respiratory. B. Musculoskeletal. C. Endocrine. D. Cardiac.

C. Endocrine. Diabetes is a disease process that occurs due to a disease of the endocrine system and subsequently affects all other systems.

One of the patients on the unit is on airborne precautions due to suspected tuberculosis. To rule out the disease, the doctor has ordered sputum specimens to be collected. What is the best daily time for the nursing assistant to collect the specimens? A. Before a meal. B. After a meal. C. First thing in the morning. D. Last thing before the patient goes to sleep.

C. First thing in the morning. The sputum produced upon awakening is the most concentrated sputum and will yield the most accurate result.

A patient has a fever and describes feeling very uncomfortable. Which of the following recommendations is best for the nursing assistant to provide? A. Give the patient a backrub. B. Administer Tylenol 500mg PO. C. Give the patient a cool washcloth to be placed on the forehead. D. Suggest the patient sit outside in the fresh air.

C. Give the patient a cool washcloth to be placed on the forehead. A cool washcloth can make a patient with a fever feel better. The nursing assistant may not administer medications.

A client who has Alzheimer's disease is told by the nurse assistant to brush his teeth. He shouts angrily, "Tomato soup!" Which of the following actions by the nurse assistant would be correct? A. Focusing on the emotional reaction. B. Clarifying the meaning of his statement. C. Giving him step-by-step directions. D. Doing the procedure for him.

C. Giving him step-by-step directions. The client is experiencing an inability to recognize or name objects (agnosia) and needs single step instructions. Provide verbal connections about using implements.

Legally, clients' charts are: A. Owned by the government since it is a legal document. B. Owned by the doctor in charge and should be kept from the administrator for whatever reason. C. Owned by the hospital and should not be given to anyone who requests it other than the doctor in charge. D. Owned by the client and should be given by the nurse to the client as requested.

C. Owned by the hospital and should not be given to anyone who requests it other than the doctor in charge. A client's chart is the property of the facility. It is the facility which sets the policy and makes appointments for viewing of the chart. Clients do have the right to read the information in their charts. Nevertheless, they do not have the right to see the chart on demand or remove anything from the chart, or remove the chart from the facility. The chart is not a property of the government. It can be used in court as evidence of the client's problems, treatments, and care, if proper steps are followed.

The nursing assistant would suspect that one of her patients is having a problem with swallowing if she notices which of the following? A. Completing a meal over the course of fifteen minutes. B. Chewing very slowly. C. Pocketing of food. D. Uneven chewing.

C. Pocketing of food A patient who pockets food may be having a difficult time swallowing.

A client under the nursing assistant's care suffers from chronic "foot drop". The nursing assistant can expect to find which of the following devices in the client's room? A. A wedge B. A mechanical lift C. Positioning boots D. Two extra pillows

C. Positioning boots Positioning boots. The boots will ensure that the feet are dorsiflexed to prevent contractures and discomfort.

The nursing assistant is aware that the responsibility for keeping an accurate I&O record is part of her duties. If the client is incontinent, how should she document the output? A. Inform the nurse that the client has voided or defecated. B. Do not document at all since it cannot be measured. C. Record on the output side of the I&O sheet each time the bed is wet. D. Review the client's intake and record the same amount on the output side of the I&O sheet.

C. Record on the output side of the I&O sheet each time the bed is wet. If the client is incontinent (cannot control bowels and/or urine), record this on the output side of the I&O sheet each time the bed is wet. Even though the urine cannot be measured, it will be obvious that the client's kidneys are functioning.

When the nursing assistant brings the client his tray for lunch, the client repeats questions twice before remembering the answer. The nursing assistant knows that the client had a fall two days ago. Which of the following actions is correct? A. Assess the client's head for bruising. B. Take the client's temperature. C. Report it to the nurse immediately. D. Assume the client is forgetful.

C. Report it to the nurse immediately. Memory loss after a fall can indicate a concussion. Report it to the nurse immediately.

When caring for a patient, the nursing assistant notices that the patient is bleeding around an IV site. Which of the following is the most appropriate action to take? A. Clamp the IV catheter and tell the nurse. B. Tell the nurse when she happens to see her. C. Report it to the patient's nurse immediately. D. Report it to the nursing supervisor.

C. Report it to the patient's nurse immediately This should be reported to the patient's nurse immediately

The nursing assistant cares for a client who is depressed. One day, the client states "I can't go on any longer. I have made a plan to kill myself. I don't know if I would follow through with it, but it seems much better than living this life any longer." Which of the following is the correct action? A. Report the situation to the physician. B. Ask the patient, "Can you tell me more about your feelings?" C. Report the situation to the nurse in charge. D. Reassure the patient by saying, "It's not that bad. You'll feel better tomorrow."

C. Report the situation to the nurse in charge. This patient is no longer just depressed; they are suicidal. Having a plan puts them at increased risk, and they need to be reported to the nurse for their own safety.

A client is receiving oxygen therapy via face mask. Which of the following is contraindicated for this client? A. Eating his lunch. B. Use of cotton bedclothes. C. Shaving using an electric razor. D. Talking with visitors.

C. Shaving using an electric razor. A client who is in oxygen therapy should have safety measures implemented in order to prevent explosion. Use of electric razors or hair dryers while the oxygen is running is not allowed. Combing a client's hair can also create a spark of electricity from his hair that could set off an explosion. The face mask can be removed if the client wishes to eat and converse with visitors. Use of cotton bedclothes is also encouraged to decrease static electricity.

Fecal impaction may present with which of the following symptoms? A. Dark urine. B. Excessive flatulence. C. Small, watery leakage of stool. D. Abdominal pain.

C. Small, watery leakage of stool. The watery leakage of stool around a blockage is the most specific sign of fecal impaction, also known as a bowel obstruction.

What type of client may opt to receive hospice care? A. Client with kidney disease. B. Client with cancer. C. Terminally ill client. D. Client with diabetes.

C. Terminally ill client. Terminally ill clients may receive hospice care, which is designed to relieve pain rather than to cure disease.

The nursing assistant takes the blood pressure of a patient known for "running low." To her surprise, the reading is 155 over 85. Which of the following factors might be directly responsible? A. The patient denies skipping any medication. B. The patient is stressed. C. The blood pressure cuff is too tight. D. The patient is lying in bed.

C. The blood pressure cuff is too tight. The blood pressure cuff size is a direct influence on the reading. The blood pressure will read higher with a tight cuff and lower with a cuff that is too large.

Which of the following statements is correct pertaining to binders application? A. A breast binder can be applied for breastfeeding mothers to relieve discomfort. B. Straight abdominal binders are applied when the client is sitting on a chair. C. The double T-binder is specifically used for male clients. D. When securing a straight abdominal binder, help the client in a side-lying position to close it at the back using safety pins.

C. The double T-binder is specifically used for male clients. T-binders secure dressings in place after rectal and perianal surgeries. The double T-binder is for men, while the single T-binder is for women. A breast binder is specifically used to support the breasts after breast surgery; not by breastfeeding mothers. Straight abdominal binders are applied with the person supine. It is secured in front of the body by safety pins, Velcro, zippers, hooks, or other closures. The top part is at the person's waist. The lower part is over the hips.

Which of the following would be considered an example of battery toward a patient? A. The nursing assistant cleans the resident's glasses. B. The nursing assistant asks for permission before touching the resident to assist them to the bathroom. C. The nursing assistant bathes the resident without his or her permission. D.The nursing assistant keeps a resident isolated from others as a form of punishment.

C. The nursing assistant bathes the resident without his or her permission. Bathing a resident without his or her permission is an example of battery. Keeping a resident isolated from others as a form of punishment is an example of involuntary seclusion.

Which of the following is an example of a nursing assistant's desired characteristic of reliability? A. The nursing assistant lets the nurse know when a patient states he is in pain. B. The nursing assistant monitors a patient's vital signs. C. The nursing assistant completes a task designated by the nurse in a timely manner. D. The nursing assistant clocks in fifteen minutes after her shift began.

C. The nursing assistant completes a task designated by the nurse in a timely manner. Completing tasks as asked indicates reliability. Monitoring vital signs is good, but too general. Communication and tardiness are separate concepts from reliability.

The nursing assistant overhears the nurse say to the patient that he has a "bulging tympanic membrane." What does this most likely mean? A. The patient is in pain. B. The patient has a viral illness. C. The patient has an ear infection. D. The patient should clean his ears more frequently.

C. The patient has an ear infection. The tympanic membrane is more commonly known as the eardrum. A bulging, tympanic membrane typically indicates an ear infection, not necessarily a viral illness.

Use of which of the following articles or types of clothing would help a client with osteoarthritis perform activities of daily living adequately? A. Zippered clothing. B. Tied shoes to promote stability. C. Velcro clothing, slip-on shoes, and rubber grippers. D. Buttoned clothing, slip-on shoes, and rubber grippers.

C. Velcro clothing, slip-on shoes, and rubber grippers. Velcro clothing, slip-on shoes, and rubber grippers make it easier for the client to dress and grip objects. Zippers, ties, and buttons may be difficult for the client to use.

CPR (Cardiopulmonary resuscitation) should be performed when: A. a client is unconscious. B. a client is choking. C. a client has no pulse and is not breathing. D. a client has a pulse but is not breathing.

C. a client has no pulse and is not breathing. CPR is performed on a client that has no pulse and is not breathing.

One of your clients just had a stroke and is manifesting receptive aphasia. Clients with receptive aphasia: A. are unable to speak. B. have no difficulty in understanding spoken or written language. C. are not able to express themselves meaningfully through speech. D. speak very loudly at all times.

C. are not able to express themselves meaningfully through speech. Receptive aphasia is also known as Wernicke's aphasia. It is a type of aphasia in which an individual is unable to understand language in its written or spoken form. Even though they can speak using grammar and syntax, they usually have difficulty expressing themselves meaningfully through speech. People with receptive aphasia are typically unaware of how they are speaking and don't realize that their speech lacks meaning.

A 52-year-old homeless man has just been admitted to the ER with a core body temperature of 90.2 degrees F. The doctor diagnoses the man with hypothermia. The nursing assistant knows that the organ most under stress from the low body temperature is the: A. lungs. B. liver. C. heart. D. ears.

C. heart. The heart may fail or go into an arrhythmia from the drop in body temperature

When helping a client with left-sided weakness due to a CVA, the nursing assistant should position the client's cane: A. in front of the client. B. on the left side. C. on the right side. D. away from the client.

C. on the right side. The nursing assistant should place the cane on the side that is the strongest so that it can support the weak side.

When the nursing assistant identifies a client who has attempted to commit suicide, the nursing assistant should: A. call a priest. B. counsel the client. C. report immediately to the nurse. D. refer the matter to the police.

C. report immediately to the nurse. By doing this, the nursing assistant is ensuring the safety of the client. The nurse can then refer the client to the healthcare provider for further assessment and planning for proper care. The other choices are not included in your responsibilities as nursing assistant.

A patient says that her visitor is unable to come during visitor hours and asks if she could be accommodated. The nursing assistant: A. reviews the issue with the patient's nurse before answering. B. says, "Of course! That would be fine." C. reviews the issue with the charge nurse before answering. D. says, "I'm sorry, that's not our policy here."

C. reviews the issue with the charge nurse before answering. It is appropriate to review this with the charge nurse of the unit before answering yes or no.

The nursing assistant knows that the term "pulse deficit" refers to: A. the difference between the systolic and diastolic blood pressure. B. an absence of the pulse. C. the difference between the apical and radial pulse. D. a strong pulse.

C. the difference between the apical and radial pulse. The apical pulse is assessed through a stethoscope placed over the heart, while the radial pulse is typically taken by applying finger pressure to the inner wrist and counting the number of heartbeats. The difference between the two pulse rates is called the pulse deficit.

A registered nurse is orienting a newly certified nursing assistant to the unit. The nurse mentions that sometimes culturally diverse clients who speak a different language are admitted to their unit. In communicating with these clients, the nursing assistant should: A. speak loudly and slowly. B. stand close to the client and speak slowly. C. use an interpreter to speak to the client. D. speak to the client and family together to increase the chances that the topic will be understood.

C. use an interpreter to speak to the client. Having an interpreter present during the communication is the best method to be practiced when communicating with clients who speak a different language. This is arranged by the nurse. Speaking to the family is inappropriate because it violates privacy and does not ensure correct translation. The other two choices are inappropriate and are ineffective ways in which to communicate.

The nursing assistant knows that residents on bedrest must be turned every A. 6 hours. B. 8 hours. C. 1 hour. D. 2 hours.

D. 2 hours. Residents on bedrest must be turned every 2 hours to maintain skin integrity.

A client eats a bagel and one large glass of orange juice. What is the correct way to record the amount of juice? A. 480 cc B. 120 cc C. 120 ml D. 480 ml

D. 480 ml The abbreviation of "cc" is no longer appropriate in the medical field. Only 'ml' should be used. A large glass is 480 ml.

Which of the following items is necessary in order to place a patient in restraints? A. The hospital administrator's approval. B. The charge nurse's approval. C. Physical restraints. D. A physician's order.

D. A physician's order. The physician needs to order restraints before they can be legally applied. No one else can ask for restraints for a patient or it is considered battery.

Which of the following bedtime snacks should a patient choose in order to increase their intake of vitamin D? A. Some pretzels. B. A cookie. C. An apple. D. A warm glass of milk.

D. A warm glass of milk. Milk and other dairy products are usually fortified with vitamin D. This is the best snack to increase intake.

The nursing assistant receives her assignment for the shift and notices that she does not have a nurse assigned to her group. What action should she take next? A. Offer to team up with another nursing assistant to give medications. B. Begin gathering medications she must give. C. Loudly complain about the situation. D. Alert the charge nurse to the situation.

D. Alert the charge nurse to the situation. Medications may not be given by a nursing assistant. Alert the charge nurse to ensure that there is a nurse provided for each client in the assignment.

The nursing assistant knows that urine is normally: A. Dark in color and foul-smelling. B. Dark yellow. C. Clear, dark yellow. D. Clear, pale yellow.

D. Clear, pale yellow. Clear, pale yellow urine indicates a well-hydrated patient.

Which is NOT a rule for collecting specimens? A. Follow the rules of medical asepsis. B. Use the correct container. C. Label the container accurately. D. Collect the specimen when you have time.

D. Collect the specimen when you have time. Collecting the specimen at the convenience of the nursing assistant is not a rule to follow. It should be collected at the correct time. Specimens are collected and tested to prevent, detect, and treat disease. The doctor orders what specimen to collect and the test needed.

A nursing assistant answers an incoming phone call only to find out that the caller was calling a different unit. How should the nursing assistant facilitate the call transfer? A. Ask the caller what telephone number he is trying to reach. B. Ask the caller to "Please hold, an operator will get to you shortly", then go back to unfinished tasks. C. Refer the call to the nurse on duty. The nurse will transfer the call herself. D. D. Tell the caller that you are going to transfer the call and give the phone number in case the call gets disconnected or the line is busy.

D. D. Tell the caller that you are going to transfer the call and give the phone number in case the call gets disconnected or the line is busy. Nurse aides may have to answer phone calls at the nurses' station or in the client's room. Good communication skills are needed. Giving the phone to the nurse will only delay time and may hamper an emergency call. In transferring a call, first find out who is calling and transfer calls only if appropriate. Respond politely by referring the caller to the operator instead of putting them on hold and eventually putting the phone down. Asking the caller for the phone number that he is trying to call is not the initial response either.

A nursing assistant watches a nurse teach a client about heart failure. The client has many questions and seems more confused rather than less. Which of the following strategies is best in regard to teaching? A. Give the client a DVD to watch about heart failure. B. Have the client repeat back what the nurse has said. C. Give the client a brochure about heart failure. D. Encourage the client to form more of a discussion with the nurse in order to understand better.

D. Encourage the client to form more of a discussion with the nurse in order to understand better. The more involved a client is in learning, the more they will remember and understand.

A client who has not had a bowel movement in four days would receive the most benefit from which of the following procedures? A. Endoscopy B. Colonoscopy C. Catheterization D. Enema

D. Enema An enema will help the patient in expelling fecal matter before it can become impacted.

All of the following factors may interfere with elimination EXCEPT: A. Infection. B. Aging. C. Medications. D. Family stress.

D. Family stress. Family stress does not typically interfere with elimination. Aging, medications, and infection do have a direct effect on elimination

What is the best way for a nursing assistant to prevent infection? A. Use standard precautions when caring for residents. B. Apply an antiseptic hand rub before and after caring for residents. C. Wear gloves when in contact with body fluids. D. Frequent hand washing.

D. Frequent hand washing. Frequent hand washing is the best way to prevent infection without a doubt. The other measures are supportive.

What protective equipment should be worn when changing an incontinent patient? A. Gloves, gown, and a mask. B. Mask and gown. C. N-95 mask. D. Gloves and gown.

D. Gloves and gown. The nursing assistant should wear a gown and gloves at most as correct contact precautions

Which of the following methods should be used to collect a specimen for urine culture? A. Have the client void in a clean container. B. Clean the foreskin of the penis of uncircumcised men before specimen collection. C. Have the client void into a urinal, and then pour the urine into the specimen container. D. Have the client begin the stream of urine in the toilet and catch the urine in a sterile container midstream.

D. Have the client begin the stream of urine in the toilet and catch the urine in a sterile container midstream. Catching urine midstream reduces the amount of contamination by microorganisms at the meatus. Voiding in a urinal doesn't allow for an uncontaminated specimen because the urinal is not sterile. When cleaning an uncircumcised male, the foreskin should be retracted, and the glans penis should be cleaned to prevent specimen contamination. Voiding in a clean container is done for a random specimen, not a clean-catch specimen for urine culture.

What is the difference between Sims position and left lateral position? A. In Sims position, a pillow is placed between the patient's knees to prevent them from touching. B. In lateral position, the patient's head is elevated to 15 degrees on two pillows. C. In lateral position, the patient's undermost arm is positioned laterally and parallel to the patient's back. D. In Sims position, the patient's undermost arm is positioned laterally and parallel to the patient's back.

D. In Sims position, the patient's undermost arm is positioned laterally and parallel to the patient's back. This correctly describes how Sims position is different than left lateral position. A pillow is placed between the knees in both positions listed.

The nurse aide was asked by the licensed nurse to change the nonsterile dressing of a client. Which of the following statements is best when pertaining to this situation? A. Tactfully refuse the delegated task because you are limited in changing dressings on your own. B. After the wound has been cleansed, apply clean dressings and tape completely around the edges of the bandage. C. In cleansing the wound, start from the surrounding skin towards the wound in longitudinal strokes. D. In changing a dressing, always note the color, odor, amount, and consistency of the drainage on the old dressing.

D. In changing a dressing, always note the color, odor, amount, and consistency of the drainage on the old dressing Dressings that do not require the use of sterile technique or to apply medication to the wound will often be assigned to your care. Make sure that you follow the correct steps in doing the procedure such as cleansing the wound and the skin using circular motions and start from the clean areas to the dirty. The wound is considered clean and the skin dirty. Apply clean dressings afterwards. Hold all dressings by the corners as you apply them. Do not contaminate the center of the bandages. Tape the dressing in place, leaving the edges free. Do not tape completely around the edges of the bandage.

Which of the following statements is true about Alzheimer's residents? A. An increased appetite is common as Alzheimer's progresses. B. Residents can never be reoriented because they will immediately forget it. C. The resident may become confused, but hallucinations are never a part of Alzheimer's. D. It is important to maintain a routine to avoid confusion and overstimulation.

D. It is important to maintain a routine to avoid confusion and overstimulation. Maintaining a routine is incredibly important to Alzheimer's patients. Hallucinations and a decrease in appetite are common. It is important to frequently reorient the patient.

A nursing assistant must obtain the blood pressure of a client in airborne isolation. Which of the following methods is best to prevent transmission of infection to other clients by the equipment? A. Dispose of the equipment after each use. B. Wear gloves while handling the equipment. C. Use only the equipment with other clients in airborne isolation. D. Leave the equipment in the room for use only with that client.

D. Leave the equipment in the room for use only with that client. Leaving equipment in the room is appropriate to avoid organism transmission by inanimate objects. Disposing of equipment after each use prevents transmission of organisms but isn't cost-effective. Wearing gloves protects the nursing assistant, not other clients. Using equipment for other clients spreads infectious organisms among clients.

The nursing assistant knows that the term "NPO" means: A. Bedrest only. B. No oral temperatures are to be taken. C. Liquid diet. D. Nothing by mouth.

D. Nothing by mouth. NPO is a latin abbreviation that stands for "nil per os" or "nothing by mouth." It indicates that the client is not allowed food, fluids, or oral medications.

A patient is on a clear liquid diet. Which of the following is NOT allowed on this diet? A. Water B. Tea C. Coffee D. Orange juice with pulp

D. Orange juice with pulp Orange juice with pulp is not allowed — the pulp is not considered part of "clear liquid." Tea, coffee, and water are all allowed on the clear liquid diet.

The term grievance refers to which aspect included in the Patient Bill of Rights? A. There is no lifetime monetary limit on essential care. B. Patients are not allowed to call doctors at home. C. Patients have access to their health information at all times. D. Patients have the right to file a complaint without fear or penalty.

D. Patients have the right to file a complaint without fear or penalty. The ability to file a grievance in a nursing home or other nursing care facility is considered a legal right as defined by the Patient Bill of Rights.

It's a busy day in the ward and the nurse on duty is now preparing the medicines of her patients on the medication tray. She hands you a tube of Teramycin ointment and gives you instructions to apply it to a patient's eyes. How would you respond to this? A. Ask the nurse to demonstrate it to you for a clearer and better understanding of the procedure. B. As assistant to the nurse, follow the nurse's request and apply the ointment to the patient's eyes. C. Ask the nurse to be with you during the application of the ointment. D. Politely refuse the nurse's request and explain your job limitations as a nursing assistant.

D. Politely refuse the nurse's request and explain your job limitations as a nursing assistant. You must work under the direction of a licensed nurse or doctor. Your job responsibilities are limited to those specified in your job description. Limitations often include giving medications (includes applying prescription skin creams, lotions, or ointments), taking orders from a doctor, and performing any procedures prohibited by law or by the employing facility. When in doubt about performing any function or task for which you are unfamiliar or unsure, consult your immediate supervisor. In medicine, the adage "Do no harm" applies to your practice as well.

Which of the following aspects of care is important for a confused client? A. Checking the client's blood sugar every hour. B. Asking the client their name. C. Keeping the client contained in their room. D. Reorienting the client frequently with clocks, calendars, and family mementos.

D. Reorienting the client frequently with clocks, calendars, and family mementos. Reorienting the patient frequently is the most important aspect of care. Keeping the client locked in their room could agitate them, as could asking them their name (which they might not remember).

A patient who is immobile may experience which of the following feelings? A. Confusion. B. Laziness. C. Happiness. D. Sadness.

D. Sadness. This patient may feel sad due to the limitation of their illness.

The nursing assistant cares for a client with AIDS. The nursing assistant knows that AIDS patients require what type of precautions? A. Droplet. B. Contact. C. Respiratory. D. Standard.

D. Standard. AIDS patients require standard precautions. Gloves must be worn at all times when handling blood or other body fluids.

A client is placed on suicide precautions. During the care planning conference, the care plan for this client was discussed by the nursing staff. Which of the following tasks would you anticipate the licensed nurse will delegate to you in ensuring the client's safety? A. Don't allow him to leave his room. B. Remove all sharp and cutting objects. C. Give him the opportunity to ventilate his feelings. D. Stay with him at all times.

D. Stay with him at all times. Clients on suicide precautions need constant observation by a staff member. This means that clients are in direct sight of, and no more than 2 to 3 feet away from, a staff member for all activities, including going to the bathroom. Not allowing him to leave his room and removing sharp and cutting objects are part of providing a safe environment, however the availability of an able staff member is a higher priority. Conversing with the client will come after his safety is established.

The nursing assistant knows that signs of hypoglycemia include which of the following? A. Tachycardia. B. Hot and dry skin. C. Polyuria. D. Sweating.

D. Sweating. Sweating, as well as confusion and tremors, are signs of hypoglycemia.

Which of the following is an example of emotional lability? A. The patient gets upset after a long day and blames it on tiredness. B. The patient gets upset when he learns he has been diagnosed with cancer. C. The patient gets upset when he does not receive a plate in his favorite color. D. The patient gets upset after telling the nurse immediately prior how happy he is.

D. The patient gets upset after telling the nurse immediately prior how happy he is. Switching quickly from happy to sad, or mad to peaceful, is the definition of emotional lability.

A resident is ordered to be in High Fowler position for each meal. Which of the following descriptions is the most accurate depiction of High Fowler position? A. The patient lies on their stomach for twenty minutes prior to eating. B. The patient's bed is at a 60 degree angle with the feet propped up. C. The patient's bed is at a 30 degree angle with the patient slightly slumped over to the left. D. The patient's bed is at a 90 degree angle and the patient is positioned sitting up.

D. The patient's bed is at a 90 degree angle and the patient is positioned sitting up. High Fowlers is a description of the patient sitting straight up in bed, meaning the bed itself has to be at a 90 degree angle to support them.

Which of the following are examples of fluid output that need to be recorded on the I&O sheet? A. Urine only. B. Urine and blood loss. C. Urine, blood loss, and excessive perspiration. D. Urine, emesis, blood loss, and excessive perspiration.

D. Urine, emesis, blood loss, and excessive perspiration Fluid output is the sum total of liquids that come out of the body. Most fluid is discharged from the body as urine. Output also includes emesis (vomitus), drainage from a wound, loss of blood, and excessive perspiration. Every time the client uses the urinal, emesis basin, or bedpan, the urine and other fluids must be measured. For perspiration, wound discharges, or bleeding, indicate what was wet, how wet, the size of the wet area, and the time it occurred.

Which action is incorrect when flossing the client's teeth? A.Hold the floss between the middle fingers of each hand. B. Make sure you also floss the back side of the very last tooth on the right, left, top, and bottom of the mouth. C. Move the floss gently up and down between the teeth. D. Use a new piece of floss for each tooth.

D. Use a new piece of floss for each tooth. It is unnecessary to use a new piece of floss for each tooth. Break off an 18-inch piece of floss from the dispenser; this will do for all the teeth. Just move to a new section of floss after every second tooth is flossed. The other choices are correct steps in flossing.

A client was fitted with a hearing aid. She understands the proper use and wear of this device correctly when she says that the device is turned on and adjusted to a: A. therapeutic level. B. preset level. C. prescribed level. D. audible level.

D. audible level. The hearing aid should be adjusted to an audible level that the client can tolerate. A hearing aid helps the person hear more in both quiet and noisy environments.

The nursing assistant speaks with the nursing facility's ombudsman. The role of this position is to: A. care for patients as if they were their own family. B. make residents as happy as possible. C. assist residents to set up insurance and policy claims. D. investigate residents' complaints and bring them to the attention of the correct authorities.

D. investigate residents' complaints and bring them to the attention of the correct authorities. The ombudsman's job is to ensure that residents' complaints are heard.

Cheyne-Stokes respirations occur in a client who: A has a history of chronic respiratory issues. B. is unconscious. C. is recovering from an asthma attack. D. is close to death.

D. is close to death. Cheyne-Stokes respirations are a breathing pattern marked by increased respirations, labored breathing, and periods of apnea (no breathing). It is important to report these signs if discovered in a resident who is not expected to show them.

A COPD client recently admitted to the floor needs constant oxygen therapy. When assisting this patient, the nursing assistant can: A. turn the oxygen on and off. B. start the oxygen. C. decide what device to use. D. keep the connecting tubing secure and free of kinks.

D. keep the connecting tubing secure and free of kinks. The job of the nursing assistant is to make sure there are no kinks in the tubing and to secure the connecting tubing in place. The other choices are all responsibilities of a physician.

When making the patient's bed, the nursing assistant knows it is most important to: A. change the pillow cover every four hours. B. use linen that has only been in the client's room. C. inspect the sheets for softness. D. straighten the sheets to reduce wrinkle formation.

D. straighten the sheets to reduce wrinkle formation. Wrinkles and creases in the sheets can contribute to bed sores.

A client who suffered a left-sided stroke one year ago has unresolved aphasia. The nurse knows that the term aphasia means: A. that the client is confused. B. that the client is unable to void. C. that the client is unable to understand and process language. D. that the client is unable to speak.

D. that the client is unable to speak. The term "aphasia" means that the client is unable to speak, or may have difficulty finding words at times.

Which of the following options is the best method to prevent insomnia? A. Ensure the client eats one apple per day. B. Encourage the client to take several naps daily. C. Encourage the client to take several walks around the facility daily. D. Encourage the client to remain in bed throughout the day.

Encourage the client to take several walks around the facility daily. Walking and physical activity during the day promotes rest and well-being at night.

Which of the following would be a primary indication of hepatitis? A. Hypertension B. Hyperglycemia C. Jaundice D. Hypotension

Jaundice also known as yellowing of the skin, occurs frequently in cases of hepatitis. (Liver disease)

Which of the following is a correct aspect of making an occupied bed? A. Place soiled linen on the floor until the bed has been remade with clean sheets. B. Mitering the corners of the new sheet is no longer recommended. C. Lower the bed to the lowest level when the procedure is complete. D. Avoid raising the bed rails unless absolutely necessary.

Lower the bed to the lowest level when the procedure is complete. Lowering the bed to the lowest level is important for safety. Mitering the corners of sheets is recommended, as is raising side rails. Never place soiled linens on the floor.

A nurse obtain an order from a physician to restrain a client by using a jacket restraint and delegates a nursing assistant to assist in the restraining of the client. Which of the following observations indicates inappropriate application of the restraint by the nursing assistant? A. A safety knot in the restraint straps. B. Restraint straps that are safely secured to the side rails. C. Jacket restraint straps that do not tighten when force is applied against them. D. Jacket restraint secured so that two fingers can slide easily between the restraint and the client's skin.

Restraint straps that are safely secured to the side rails The restraint straps should be secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it and allows quick and easy removal of the restraint in case of emergency. The jacket restraint should be secured, and one to two fingers should slide easily between the restraint and the client's skin

Client with osteoarthritis may be on bed rest for prolonged period. The nursing assistant is aware that she should: A. encourage coughing and deep breathing and limit fluid intake. B. provide only passive range of motion, and decrease stimulation. C. have the client lie as still as possible, and give adequate massage. D. turn the client every 2 hours, and encourage coughing and deep breathing.

Turns the client every 2 hours and encourage coughing and deep breathing A bedridden client needs to be turned every 2 hours, have adequate nutrition, and cough and deep breathe to prevent potential complications of pressure ulcers and pneumonia. Massage can minimize the pain, but placing the client immobile is not the correct answer. Active and passive range of motion exercises and hydration are also appropriate answers to prevent contractures and promote skin integrity.