Basic Nursing Skills
The proper temperature for a soapsuds enema is
105°F The proper temperature for a soapsuds enema is 105°F. This is slightly warmer than body temperature, or lukewarm.
To convert four ounces of liquid to milliliters (ml), the nurse aide should multiply 4 by
30 ml When converting milliliters (ml) to ounces (oz), remember that one ounce is approximately 30 ml. Although one ounce is slightly less, the amounts are considered equal by doctors and pharmacists.
What is the correct measurement of urinary output?
300 cc 300 cc is a metric measurement meaning 300 cubic centimeters. In medicine around the world, the metric system is used for all length, weight, volume, and temperature measurements. The metric system is based on powers of ten, making it simpler and more precise than other methods of measurement.
How many tips does a quad-cane base have?
4 A quad-cane has four tips to provide a broad base to support the client while walking. The client holds the cane on the strong or unaffected side. To walk, the client should place the cane about an arm's length away, with all four tips touching the ground at the same time. Next, the client should step forward with the weak leg, using the cane for stability.
What is an embolism?
A blood clot that moves through the bloodstream and causes obstruction An embolism is usually a blood clot that travels through the bloodstream and becomes stuck in an artery or vein. It blocks blood flow, leading to tissue damage and possibly death. Fat or air can also cause an embolism. An embolism is a medical emergency.
Mrs. Shumway's nursing care plan lists CHF (Congestive Heart Failure) as her primary dx. (diagnosis). You would expect her ADL routine to include what?
Daily am weight measurement Congestive heart failure is a chronic disease that occurs when the heart becomes weak and is no longer able to pump efficiently. It is important to monitor the client's weight. A sudden weight gain means that the client is retaining fluid. This puts a strain on the heart and lungs. The nurse aide should weigh the client every morning at the same time and record the weight. Notify the nurse of any sudden change.
Why should heat NOT be applied to a diabetic resident's feet?
Diabetics have decreased sensitivity to heat Diabetics often have neuropathy (nerve damage) and may be unable to detect if their feet are injured. The diabetic may be unable to feel temperatures, so extreme care must be taken to protect the feet from both heat and cold. Diabetics should always wear socks and shoes to prevent cuts or injuries to their feet.
What is a proper way to correct an error in charting?
Draw a single line through it There are strict guidelines on how to correct a charting error. Never erase or cover the error. Draw a single line through the error so that the entry is still visible. Add the date and your initials. Continue with the correct entry. There can be serious consequences for you and your facility if proper protocols for error correction are not followed.
What is the best way to keep a skilled nursing facility from having an unpleasant odor?
Empty bedpans and change linens in a timely manner All staff in a skilled nursing facility are responsible for maintaining a pleasant environment. Any source of odor must be dealt with at once. Bedpans and commodes should be emptied and cleaned as soon as the client finishes. All linens should be changed in accordance with the facility's policies and as needed. Soiled linens should be transferred to the laundry facilities as soon as possible. Housekeeping can clean the common areas, dining room, and client rooms to prevent odors from food or incontinent episodes.
A nurse aide is going to take Mr. Heath's vital signs. What should the nurse aide do to reduce Mr. Heath's anxiety and get him to cooperate?
Explain the procedures to Mr. Heath Before providing any care, the nurse aide must follow all the standard steps in preparation. Gather everything needed so you won't have to leave the client's room once you begin. Always wash your hands both before and after each client interaction. After confirming the client's ID, explain the procedures to the client, even for routine tasks such as taking vital signs. Allow the client to ask questions before proceeding.
What best helps reduce pressure on the bony prominences?
Flotation mattress A bedridden client can quickly develop pressure sores if he or she is allowed to remain in one position. To prevent the skin from breaking down, reposition the client at least once every two hours. Use pillows to support the client and relieve places where skin can rub, such as between the legs or at the tailbone. Always keep the skin clean and dry. A sheepskin on the bed or wheelchair provides extra padding but does not replace repositioning. Observe the skin for reddened areas and report them to the nurse. Special beds and flotation mattresses are helpful in preventing pressure sores.
A sitting or semi-sitting position with the head of the bed elevated is called
Fowler's Fowler's position is the standard way to position a client to improve oxygenation. There are several types of Fowler's position. In high Fowler's, the client sits upright in bed at a 90-degree angle to allow the chest to expand. The semi-Fowler's position raises the head of the bed to 45-60 degrees. This position is used for drainage and comfort after surgery.
What is the most comfortable position for a client with a respiratory problem?
Fowler's When a client is having difficulty breathing, the Fowler's position can provide relief. When sitting in the Fowler's position, the client is upright at 90 degrees, allowing the chest to expand as much as possible. Prone (on the abdomen), supine (on the back), and lateral (on the side) are all flat positions, which can make respiratory distress worse.
On which side should the patient lie for an enema?
Left The left Sims position is used for rectal examinations and administering enemas. The client lies on the left side, with the right knee and hip bent. It is also called the lateral recumbent or semiprone side position.
What is the recommended position for giving an enema?
Left Sims The left Sims position is used for rectal examinations and administering enemas. The client lies on the left side, with the right knee and hip bent. This position is also called the lateral recumbent or semiprone side position.
When lifting a heavy object, which muscle groups should you use?
Muscles of the legs When lifting a client or a heavy object, use your legs to position yourself to support the load. Keep your back straight and locked; do not turn or twist. Do not attempt to lift by bending forward. Bend your hips and knees to squat down. Keep the load close to your body and straighten your legs as you lift. If you have any doubts, ask a co-worker for assistance.
What can the nurse aide give a resident who has an order for NPO?
No foods or liquids NPO is a common medical term that means the client cannot eat or drink anything, including water or ice chips. A doctor may order a patient to be NPO before surgery or certain lab work. If a client is ill or has a gastrointestinal condition, the doctor may write an order to be NPO until the cause is known. The nurse aide can provide mouth care for a client who is NPO. Placing an "NPO" sign over the client's bed will remind all staff members not to give the client anything to eat or drink.
The nurse aide knows to wear what to perform resident care?
Non-skid shoes Comfortable, clean uniform A name tag The nurse aide is considered a health care professional and should dress accordingly. Each facility has a dress code policy regarding the type of uniform to wear. Clothing must be clean and free from stains, tears, or wrinkles. Shoes must be closed toe with non-skid soles. Appropriate grooming is always necessary. To prevent a nurse aide from injuring a client while giving care, the nurse aide's jewelry is usually limited to a watch and a wedding ring. A name tag is part of the standard uniform.
What is NOT a way to restrain a client?
Pain management A restraint may be either physical or chemical. Its purpose is to protect the client from harming himself or others. Only a physician may order a restraint, and guidelines are strict. A pain medication may help calm a client or relieve behavior associated with severe pain, but it is not in the restraint category.
A client is to be assisted out of bed to sit in a wheelchair. How can this procedure be made safe?
Place the bed in the lowest position Client safety during transfer begins with the bed in the lowest position. This allows the client to easily reach the floor when standing and pivoting to sit in the wheelchair. The brakes of the wheelchair should be locked and the footrests completely out of the way.
What is the term for a device used to take the place of a missing body part?
Prosthesis A prosthesis is a device that replaces a part of the body that is missing from birth or due to surgery or accidents. It helps restore function for the client and can also improve a client's appearance. A prosthesis can be made for eyes, teeth, arms, legs, joints, or breasts.
The nurse aide enters a client's room, and the client states that he has pain. What should the nurse aide do?
Report it to the nurse in charge As a CNA, you may be the first person that learns of a client's pain. Report what the client tells you to the nurse. You can try to make the client more comfortable with a position change, by arranging pillows, or by other supportive measures.
The nurse aide is going to help the client walk from the bed to a chair. What should the nurse aide put on the client's feet?
Rubber-soled slippers or shoes When helping a client ambulate, you must prevent the client from falling. Proper footwear should always be worn for any type of walking, even a short distance. Rubber-soled slippers or shoes provide traction to prevent falls. Socks, stockings, or slippers made from fabric can make the client slip or lose his or her balance. Walking in bare feet can lead to foot injuries, which is especially dangerous for diabetic clients.
What is true regarding the use of side rails on a bed?
Side rails should not be raised unless stated in the care plan Bed rails can be a safety risk for some clients, who might be injured while trying to get out of bed. Clients can also become trapped or strangled in bed rails. Using bed rails without permission can be seen as an attempt to restrain the client. Always follow the care plan regarding the use of bed rails.
What type of people provide treatment for persons who have difficulty talking due to disorders such as a stroke or physical defects?
Speech therapist If a client is unable to speak clearly or has trouble forming words, a speech therapist can alleviate speech problems caused by strokes, physical defects, or swallowing disorders. Speech therapists work with both adults and children. They are qualified to evaluate, diagnose, and treat clients.
The RN assigns you a task that is in your job description. What statement is FALSE?
The RN should delegate every non-RN task to you Although the RN can assign or delegate tasks that are in your job description, he or she must ensure that you know how to do the task and that it's beneficial to the patient. Some non-RN tasks may be outside the scope of your CNA practice. If so, inform the RN.
Who is responsible for the entire nursing staff and the activities involved in providing safe care?
The director of nursing The Director of Nursing (DON) is a registered nurse who oversees all patient care at a facility. The DON supervises all nursing staff, manages budgets, and handles patient and family issues that staff RNs can't resolve.
What is a major reason for urinary incontinence in the elderly?
The muscle that keeps urine in the bladder weakens As part of the aging process, a client may experience urinary incontinence because of weakness of the muscle that keeps the urine in until the client can get to the toilet. Another possible reason is that the bladder itself doesn't contract to expel all the urine. Bladder infections and prostate problems can also contribute to incontinence. Diseases such as Alzheimer's or multiple sclerosis can also be causes.
Objective data is any information that is fact. This means that the information is unbiased and multiple people should be able to interpret the information in the same way. What is NOT an example of objective data?
The patient's pain level is 3 out of 10 Subjective data is based on an individual's interpretation of a situation. Pain level is a good example. Each person has a different pain threshold that cannot be accurately measured. Two people who have had the same surgery may report entirely different levels of pain on the Pain Scale. Subjective information is not judged, but recorded as the person states it.
Postpartum refers to
The period of time after the delivery of a baby Postpartum is a medical term that means "after giving birth." In any medical term, the prefix "post" always means "after." For example, postoperative means "after surgery" and postdischarge means "after leaving treatment." The term "partum" refers to giving birth.
In the Nursing Care Plan, you note that it is written, "O2 per N/C @3L, Orthopnea pos. as needed". As a CNA, you know that this means which of the following?
The resident is on oxygen with a nasal cannula on three liters. Assist to sit in Fowler's position Every facility has a list of approved abbreviations. The CNA should become familiar with these, for reading care plans and for preparing documentation. This nursing care plan means that the client is receiving oxygen at a constant rate of 3 liters per minute, using a nasal cannula. If the client has difficulty breathing, the CNA can assist the client to sit in a Fowler's (upright) position.
What is INCORRECT when you're recording on a patient's chart?
Use a pencil in case you make a mistake All documentation must be done in permanent ink. If you make a mistake, follow your facility's policy for correction. Usually it is a single line through the error, along with the date, the time, and your initials.
What is associated with smoking?
Vitamin C deficiency Pneumonia Heart attacks The effects of smoking can cause many diseases and medical complications. Cigarette smoking is the most frequent cause of lung cancer, and it also causes other lung conditions such as chronic obstructive pulmonary disease (COPD), emphysema, and pneumonia. Furthermore, smokers are more likely to develop heart disease and have heart attacks and strokes. Vitamins are depleted in smokers, especially vitamin C and the B vitamins.
If the resident is smoking and the nurse aide needs to take an oral temperature, what should the nurse aide do?
Wait 15 minutes to take the temperature Before taking an oral temperature, determine if the client has smoked or has had anything hot or cold to drink in the last 15 minutes. If so, wait a full 15 minutes before taking the temperature to obtain an accurate measurement.
The Heimlich maneuver (abdominal thrusts) is used on a client who has
a blocked airway The Heimlich maneuver (abdominal thrusts) is a first aid technique for helping someone who has food or an object caught in his or her upper airway. When a client appears to be choking, you must act quickly to clear the airway. First, call for help. Next, to perform abdominal thrusts, stand behind the client. Make a fist with your dominant hand. Place this fist just above the client's navel. Wrap your other hand firmly around the fist. Pull inward and upward, pressing into the client's abdomen with quick and forceful upward thrusts as if you were trying to lift the client off his or her feet from this position. Continue the abdominal thrusts in quick succession until the object is expelled.
Continuing education is
a professional standard important for keeping abreast of new developments necessary for recertification in many states For health care professionals, learning does not end at graduation. Medicine is constantly changing, and it is the responsibility of each person to be aware of new developments in their area of practice. Also, clinical standards and many states require proof of continuing education in order to renew a license or certification. During an accreditation survey, hospitals and facilities must show proof that staff members are receiving ongoing training and education.
Mrs. Hernandez had a hip replacement and is admitted to the long-term care facility for rehabilitation. Her condition is considered
acute An acute event is a new or sudden situation that is expected to resolve. Examples are a broken bone, a head cold or the flu, or an asthma attack. In this question, Mrs. Hernandez has an acute condition because she will be leaving the long-term care facility after she finishes rehabilitation. A chronic condition develops slowly and continues to progress. Examples are heart disease, diabetes, and osteoporosis.
The loss of the ability to express oneself is known as
aphasia When a client has suffered a stroke or some other head injury, the speech center of the brain can be damaged, resulting in aphasia. Chief signs of aphasia include difficulty finding appropriate words when speaking, trouble understanding speech, and difficulty with reading and writing.
A client needs to be repositioned but is heavy, and the nurse aide is not sure that she can move the client alone. The nurse aide should
ask another nurse aide to help Clients or objects that are heavy should never be moved or lifted by one person. The risk of falls or injuries to both the client and the nurse aide increases with heavy loads. Ask for assistance before attempting to pull or roll a heavy patient. Use good body mechanics by using your leg muscles to avoid back injury.
A patient appears paler than usual. The nurse aide should
ask the patient how he feels and take his vital signs immediately Whenever you notice a change in the client's condition, stop to assess the client and take vital signs. If the client is able to respond, ask the person how he or she feels. Report the change, vital signs, and client's response to the nurse. When charting, document what you observed and did.
To be sure that a client's weight is measured accurately, the client should be weighed
at the same time of day Obtaining the client's weight is an important part of assessment. Weight should be measured at the same time every day. Morning is the best time. Ideally, to get the most accurate or dry weight, use the same scale each time and weigh the client after the first void and before breakfast.
Wasting or a decrease in the size of a muscle is called
atrophy Muscle atrophy is a loss of muscle mass. The main cause of atrophy is lack of physical activity, which may be due to injury or disease. After an injury such as a herniated disc or a broken leg, the muscles are often immobile or painful to move. Diseases which lead to atrophy include multiple sclerosis, anorexia nervosa, and AIDS.
To lift an object using good body mechanics, the nurse aide SHOULD
bend the knees and keep the back straight When lifting, you should maintain proper spinal position. The risk of injury to the lower back increases if you use the back muscles, bend at the waist, twist, or try to lift a load that is too heavy. Common injuries associated with lifting are strains, sprains, and herniated discs. For heavy loads, always find another person to help.
While eating dinner, a client starts to choke and turn blue. The nurse aide SHOULD
call for assistance and perform the Heimlich maneuver (abdominal thrusts) Abdominal thrusts (the Heimlich maneuver) is the best response to choking. Calling for assistance as you prepare to do abdominal thrusts will alert others to the emergency. You can try a quick back slap, but if the food is not immediately dislodged, quickly start abdominal thrusts. To perform abdominal thrusts, stand behind the client and use your hands to exert upward pressure on the bottom of the diaphragm.
Most of our calories should come from
carbohydrates A balanced diet is essential for health. When the client consumes nutrients in the right combination of calories, the person's desired weight is maintained. Carbohydrates supply fuel for the body, so 45 - 65% of calories should come from carbohydrates. The energy is stored in the muscles and liver for immediate or future use, as well as for the brain to function. Fat and protein have important roles, but they are not good as energy sources.
Meal trays have arrived. Before serving each tray, the nurse aide should
check each armband, even on familiar patients Some clients have special diets, severe food allergies, or strict fluid restrictions. Before serving a meal tray, always check the client's ID band or tag and match it to the correct tray. Although it can be tempting to skip this step in a long-term care facility, the nurse aide is legally responsible for verifying the identity of each client before serving food or giving care.
When caring for a resident with an indwelling Foley catheter, you should
check the bag and tubing frequently for adequate urinary flow When a client has an indwelling Foley catheter, the nurse aide should check that the tubing is open so that the urine can flow from the bladder. After each position change or whenever the client returns to the bed or chair after being up, ensure that the tubing is not kinked or closed. Finally, the bag should be lower than the bladder to prevent backflow.
When caring for a client who uses a protective device (restraint), the nurse aide SHOULD
check the client's body alignment When a physician orders a restraint for a client, the staff must strictly follow the protocols to maintain the client's safety. The nurse aide should become familiar with the policies regarding restraints. The policy will state the defined times to monitor the client, directions for reporting on the client's status, and directions for documenting all observations.
The nurse aide sees a client spill water on the floor in the hall. Another client is walking down the hall. The nurse aide SHOULD
clean up the spill Falls can lead to serious injury and complications, especially among elderly or very ill clients. Every staff member should be constantly alert for potential hazards such as spills and immediately take care of the situation. Never ignore a potential cause of a fall. If the spill is caused by blood or body fluid, follow the protocol for decontamination and wear Personal Protective Equipment (PPE).
The nurse aide is walking with a client confined to a wheelchair when the facility fire alarm system is activated. The client becomes excited from the noise. The nurse aide SHOULD
comfort the client while moving the person to a safe place The nurse aide should be familiar with all fire safety policies and protocols. When a fire alarm sounds, all staff must respond to keep clients safe. Remember "R.A.C.E." to quickly act. R = Rescue/Remove all people who can not take care of themselves. A = Alarm, if it has not already been done. Pulling the alarm can be done at the same time as rescue. C = Confine/Contain the fire or smoke by closing doors to prevent or slow the spread. Smoke is especially dangerous to everyone. E = Extinguish the fire if possible with a handheld fire extinguisher. Only try to extinguish small fires, and only as long as you can remain safe and have an escape route.
Many elderly residents lose their appetite because of
depression social isolation decrease in number of taste buds As people age, loss of appetite can be normal. But there are also specific reasons that the ability to enjoy food declines. With fewer taste buds, flavors are harder to detect; more seasoning or appealing aromas may be helpful. People who are depressed or socially isolated often don't feel like eating. Meals that are colorful, beautifully prepared, and nutritious at senior centers or other places can help elderly people look forward to eating. Other causes of loss of appetite include dental problems and side effects of medications.
The thinning of the fatty layer under the skin could cause a resident to
develop pressure sores The natural aging process causes many changes in the skin. The outer layer of skin becomes thin and appears pale and clear. Blood vessels become fragile, leading to bruising and bleeding under the skin. The fat layer also thins, so there is less padding, which increases the risk of injury and pressure sores. Rubbing or pulling on the skin can produce skin tears.
Various factors will change pulse rate. An increased pulse rate can be caused by
exercise The heart rate is lowest when the person is at rest or not engaging in physical activity. The heart rate increases when there is a need for more oxygen. Exercise always triggers a faster pulse. Other factors that raise the heart rate include pain, anxiety, stress, or too much thyroid medication.
The nursing care plan states, "Transfer with mechanical lift." However, the client is very agitated. To transfer the client, the nurse aide SHOULD
get assistance to move the client Client safety is always your highest priority. Do not try to accomplish a task alone if a patient is unable to cooperate for any reason. It is important to follow the nursing care plan, including all the steps for operating any equipment being used to move or transfer the client. Ask a co-worker to help if you have any concerns about keeping the client safe. If the client remains agitated, notify the nurse before proceeding.
To help ensure adequate circulation to prevent patient skin breakdown, you should
give back massages perform active or passive range-of-motion exercises change the patient's position frequently One of the primary responsibilities of a nurse aide is to monitor the client's skin for any signs of breakdown. During baths, dressing, or position changes, inspect the skin for redness, pallor, warmth, or bruising. Reposition at least every two hours, protecting areas that rub together, as well as the bony prominences. Massages of the back and buttocks can promote circulation. Range-of-motion exercises are also helpful. Always report any signs of breakdown to the nurse.
A patient who was given insulin in the morning is pale and sweaty and appears confused two hours later. It would be helpful to find out whether the patient
had breakfast Diabetic clients have a strict schedule regarding insulin injections and eating. Eating causes blood sugar to rise, and the insulin helps move it into the cells. Without food, the blood sugar drops quickly, causing a serious situation. Immediate treatment is necessary. Quickly check the client's blood sugar level and report it to the nurse. The client will need to eat 15 grams of glucose or a simple carbohydrate such as 1/2 cup orange juice or a tablespoon of sugar. The nurse aide should be aware of which clients are diabetic so that meals are served shortly after the clients receive insulin.
To take a rectal temperature, the nurse aide should insert the thermometer and
hold on to the thermometer until it can be removed A rectal reading is the most accurate way to measure body temperature, but it needs to be done correctly. After placing the client in the Sims position, lubricate the thermometer and gently insert it about one or two inches into the rectum. Hold the thermometer in place for two minutes to prevent it from being pushed out or advancing into the rectum. After withdrawing the thermometer, wipe it with a gauze pad, read the temperature, and place the thermometer in the "used" container.
A health care agency or program for patients who are dying is
hospice Hospice is a special type of care for patients with life-limiting conditions, their families, and their caregivers. The goal of hospice care is to maintain the patient's dignity and quality of life, while supporting each person. Hospice care does not prolong life or hasten death.
When dry, hard stool fills the rectum and will not pass, it is called
impaction Fecal impactions commonly occur in people who suffer with chronic constipation. A fecal impaction is a mass of dry, hard stool in the colon or rectum. The client is unable to pass it without assistance. The stool may need to be removed manually by inserting a gloved finger into the rectum. Enemas and laxatives may also be tried.
The exchange of oxygen and carbon dioxide takes place
in the lungs The lungs are the main organs of the respiratory system. They take in oxygen during inhalation and release carbon dioxide during exhalation. These gases are exchanged in the tiny air sacs of the lungs, called alveoli.
A bedsore or decubitus ulcer is caused by
inadequate turning One of the primary responsibilities of a nurse aide is to monitor the client's skin for any signs of breakdown that could develop into bedsores (also known as decubitus ulcers or pressure sores). During baths, dressing, or position changes, inspect the skin for redness, pallor, warmth, or bruising. Reposition at least every two hours, protecting areas that rub together, as well as the bony prominences. Massages to the back and buttocks can promote circulation. Range-of-motion exercises are also helpful. Always report any signs of breakdown to the nurse.
When transferring a client, MOST of the client's weight should be supported by the nurse aide's
legs When transferring a client, position yourself to support the client by using your legs. Keep your back straight and locked; do not turn or twist. If you bend, do so at the hips, not the waist. Before beginning the transfer, assess how much the client is able to do. If you have any doubts, always ask for assistance from a co-worker.
Supine position is
lying on the back A patient who is lying on his or her back is in the supine (pronounced "soo-pine") position. Hint: Both "supine" and "sky" start with an S. "When supine, I look at the sky."
The brain is part of the
nervous system The nervous system has two parts. The brain and spinal cord make up the central nervous system (CNS). The peripheral nervous system (PNS) is made up of all the body's nerves, which connect to the CNS. The brain sends messages through the spinal cord and nerves to control the body's muscles and organs. It also processes and interprets the information from both inside and outside the body.
NPO means
nothing by mouth NPO is a common medical term that means the client can not eat or drink anything, including water or ice chips. A doctor may order a patient to be NPO before surgery or certain lab work. If a client is ill or has a gastrointestinal condition, the doctor may write an order that the client be NPO until the cause is known. The nurse aide can provide mouth care for a client who is NPO. Placing an "NPO" sign over the client's bed will remind all staff members not to give the client anything to eat or drink.
A nurse aide notices blood in a patient's IV tubing. The aide should
notify the IV nurse When an IV is running well, the tubing should be clear and the IV site clean and dry. If you notice blood in the tubing, notify the nurse. It is beyond the scope of practice for a nurse aide to do anything with an IV.
A patient complains that her hand hurts where the IV is running. The nurse assistant notices that the hand is puffy. The nurse assistant should
notify the IV nurse that the infusion appears to have infiltrated Infiltration occurs when the IV fluid leaks into the tissue because of a dislodged or misplaced IV catheter. The nurse assistant should monitor the IV site and report if it becomes swollen, cool to the touch, or painful. The skin near the IV site may look pale. Always be careful when moving or assisting a client with an IV to avoid pulling the line.
Who supervises the work of a nurse aide?
nurse The work of a nurse aide is overseen by a registered nurse (RN) or a licensed practical or vocational nurse (LPN/LVN). The scope of practice for an RN or LPN/LVN includes having responsibility for staff who provide daily, hands-on care for clients. Open communication between the nurse aide and the supervisor makes for excellent client care.
The best way for a nurse aide to gather information about the safety and well-being of a resident is
observation As the primary staff member for providing hands-on care for a resident, the nurse aide is able to observe the resident's current condition accurately. Flow sheets provide information about the resident over time, but the nurse aide is able to assess the situation in real time.
Type 2 diabetes is
often associated with obesity and sedentary lifestyles common controllable Type 2 diabetes is the most common form of diabetes, usually occurring in adults who are obese and inactive. It is a chronic disease that requires ongoing medical management. Although there is no cure, it can be controlled with lifestyle changes such as diet and exercise. Medications can also be helpful in keeping blood sugar levels at optimal levels.
A client is paralyzed on the right side. The nurse aide should place the signaling device
on the left side of the bed near the client's hand Clients who have had a stroke often have one-sided weakness or paralysis. They may not be able to use that side of their body, or they may not even be aware of the affected side. This is called "one-sided neglect." Rehabilitation services will help the patient recover as much as possible. As the client's caregiver, you can encourage the client to use the unaffected side by placing the signaling device where the client can reach it to call for assistance.
To count respirations, one respiration includes
one inhalation and one exhalation The normal respiratory rate for adults is 12 - 18 breaths per minute. To get an accurate respiratory rate, choose a time when the client is at rest. Observe the client for one minute while counting. Each rise and fall of the chest represents one respiration. While counting, note if the client is having trouble breathing or taking full inhalations. If so, notify the nurse.
Elderly residents sometimes appear stooped over and seem to have lost height. This is due to
osteoporosis in the spinal column Osteoporosis in the spinal column can lead to a gradual loss of height and a stooped posture. The loss of calcium in the vertebrae of the spine can cause fractures and back pain, although most of the fractures are tiny and painless. Both older men and women can get osteoporosis.
Signs of poor circulation include
paleness; cold skin; and edema Poor circulation is the result of another medical condition. Peripheral artery disease (PAD) is a narrowing of the blood vessels in the arms, legs, head, or stomach, resulting in impaired blood circulation. Without a good blood supply, the skin becomes pale and cool to the touch. Edema develops when extra fluid cannot be returned to the heart. Other symptoms of PAD include numbness, tingling, pain, and muscle cramps. Other causes of poor circulation are diabetes, obesity, and varicose veins.
What type of fire can be put out with water?
paper Fire extinguishers are classified by the materials they can snuff out. Think "ABC." Class A fire extinguishers are used for paper, wood, textiles, and some plastics. Class B extinguishers are used for flammable liquids such as oil or gasoline. Class C extinguishers are for electrical fires. All fire extinguishers have labels on them to identify which type of fire they can be used on. Never use water on an electrical fire because of the risk of electric shock.
Mrs. Sparks is an 83-year-old female patient who suffers from the late effects of a CVA. She has {L} sided hemiplegia. This is
paralysis on the left side of the body A client with left-sided hemiplegia has paralysis on the left side of the body. The paralysis can be either partial or total. It occurs on the opposite side of the CVA (stroke) or brain disorder. Mrs. Sparks had a CVA on the right side of her brain, resulting in left-sided paralysis.
There are two kinds of restraints
physical and chemical There are two categories of restraints that are meant to protect the client or others. Physical restraints are devices that are designed to restrict movement. Examples are vests, hand mitts, belts, lap trays, or bed rails. Chemical restraints are medications given to control behavior such as yelling or combative behavior. All restraints require a physician's order.
For safety, when leaving a client alone in a room, the nurse aide SHOULD
place the signaling device within the client's reach After giving care, or when leaving the client's room, always ensure that the client's call signal is within reach. Clients must always have access to caregivers. For safety, the bed should be in the lowest position, with the bed rails up. Restraints may never be applied without an order from the client's doctor.
To take an oral temperature, the nurse aide should
place the thermometer under the tongue To take an oral temperature, make sure the client has not had anything hot or cold to eat or drink for 15 minutes. Place the thermometer under the client's tongue. A digital thermometer will beep when it registers the client's temperature. A glass thermometer will have a line that stops moving when it gives the reading. Note: The normal body temperature ranges for very young children, older children, and adults are different. For children aged 2 - 5 years, the normal body temperature range is 37.0°C - 37.2°C (98.6°F - 99.0°F). For children aged 5 - 10 years, the normal range is 35.5°C - 37.5°C (95.9°F - 99.5°F). For persons age 11 and up, fever is considered a temperature higher than 38 degrees C (100.4°F).
The purpose of padding side rails on the client's bed is to
protect the client from injury Side rails can keep clients from falling out of bed. Also, clients can grab on to the railing to reposition themselves. However, if the client is agitated, confused, or has a head injury or a history of seizures, padding the side rails can prevent injuries or entrapment. Some facilities have bed rail pads or bumpers in stock. You can also use a mattress pad to make a side rail pad. Make sure the bed is always in the lowest position.
When lifting, the nurse aide should have his or her feet separated in the standing position to
provide a wide base of support When feet are placed about a shoulder width apart, a comfortable and wide base of support is established. With a wide base of support, you are less likely to lose your balance. To turn, use your feet, not your back. Do not twist your back or torso while lifting.
The goal of the health care team is to
provide quality care Health care teams are based on the idea that no one has all the knowledge to do everything for a patient. By having each specialty contribute, the patient gets the best possible care.
Clean bed linen placed in a client's room but NOT used should be
put in the dirty linen container Once linen has been in a client's room, it is no longer considered clean. Each client's room may have pathogens or sources of possible infection that can be spread by objects from that room. Opened supplies or items with sterile packaging that has been opened should also be discarded, even if they have not been used.
When making an occupied bed, the nurse aide should
raise the side rail on the unattended side Making an occupied bed involves changing the bed linens while keeping the patient comfortable. Use a privacy sheet to cover the patient during the process. Always raise the side rail on the opposite side of where you are working to prevent the patient from rolling out or falling. The patient can hold onto the side rail if he or she is able to do so. Adjust the bed height to avoid injuring your back. Return the bed to its lowest level when you are finished.
A resident is NPO for tests. The nurse aide should
remove the water pitcher and glass from the room NPO is a common medical term that means the client cannot eat or drink anything, including water or ice chips. A doctor may order a patient to be NPO before surgery or certain lab work. If a client is ill or has a gastrointestinal condition, the doctor may write an order to be NPO until the cause is known. The nurse aide can provide mouth care for a client who is NPO. Placing an "NPO" sign over the client's bed will remind all staff members not to give the client anything to eat or drink.
While making an empty bed, the nurse aide sees that the side rail is broken. The nurse aide SHOULD
report the broken side rail immediately Every staff member is responsible for keeping clients safe at all times. This includes monitoring all equipment and reporting when anything needs repair. Never use broken equipment or try to create a temporary fix for equipment that is not working properly. Tag the broken bed and move it so that another client can't use it. Replace it immediately with one that has functioning side rails.
While providing denture care for a client, the nurse aide observes that the upper plate is cracked. The nurse aide should
report the damage to the nurse in charge If you notice that a client's dentures are cracked or damaged, report it to the nurse. Do not put the dentures in the client's mouth, because broken dentures can irritate or injure the gums.
The nurse aide notices on the flow sheet that a resident has not had a bowel movement for five days. The nurse aide should
report this to the charge nurse Although each person has a unique pattern of bowel movements, the normal number is 3 to 14 times a week. If the client has had a sudden change in bowel habits or is experiencing symptoms of constipation such as bloating, pain, or nausea, the cause should be investigated. Adding fiber and fluids to the diet can help prevent constipation.
The nurse aide notices that the client's radio cord is draped across a chair to reach the nearest outlet. The FIRST thing the nurse aide should do is
see if any changes can be made so that the radio can be plugged in safely All facilities must comply with the electrical safety standards of governmental and accrediting agencies. Client devices, including radios or televisions, must be approved according to the facility's policies. Cords cannot cause any potential hazards, such as tripping or falls. Extension cords are usually not allowed. The nurse aide can help the client find a place for the radio where the cord to be safely plugged in, so the client can continue to enjoy listening.
Constipation and indigestion can result from
slowed peristalsis About 75% of elderly people have slowed peristalsis (muscular contractions that move food through the intestines) because there are fewer nerves to control the gut. As a result, food does not move in an even pattern. This can cause constipation and indigestion. Any pathogens in the digestive tract have a chance to multiply, which may lead to enteric infections.
The term atrophy refers to an organ or tissue becoming
smaller because of underuse Atrophy is a loss of cells due to underuse or disease of a part of the body. When muscles are not used, they can waste away, resulting in poor strength or movement. In Alzheimer's disease, the brain atrophies, shrinking until all functions are lost.
Headaches, nausea, and pain are considered
symptoms Symptoms are the client's experience of how he or she feels. Pain, nausea, and anxiety are things that only the client can perceive and report. They may contribute to the signs that others can see, such as a higher heart rate, change of skin color, or unusual behavior, but the symptoms begin with the client.
In a report, the nurse aide is told that one of her patients has been ordered NPO after midnight. The aide should
take away the water pitcher at midnight NPO is a common medical term that means the client can not eat or drink anything, including water or ice chips. A doctor may order a patient to be NPO before surgery or certain lab work. The nurse aide can provide mouth care for a client who is NPO. Placing an "NPO" sign over the client's bed and on the client's door will remind all staff members not to give the client anything to eat or drink.
If a nurse aide needs to wear a gown to care for a patient in isolation, the nurse aide should
take the gown off before leaving the patient's room All items used for a patient in isolation must remain in the room. This includes personal protective equipment (PPE) such as gowns, gloves, and masks. Every facility has strict isolation protocols to prevent the spread of infection and disease.
A diabetic resident asks the nurse aide to cut her toenails. The nurse aide should
tell the resident that the nurse aide cannot do it but will report it to the charge nurse Diabetics often have neuropathy (nerve damage) and may be unable to tell if their feet are injured. Even trimming toenails can cause an injury. Diabetics need expert care from a podiatrist or a qualified foot care professional. You can be held liable if the client develops an infection after you cut her toenails.
A hospice specializes in the care of people who are
terminally ill Hospice care is specialized care for clients who are terminally ill. The care includes the family and caregivers. It does not attempt to cure the client. Hospice care is intended to improve the quality of life for everyone involved, by taking care of their physical, emotional, and spiritual needs.
What is a pulse oximeter used to measure?
the amount of O2 in the blood A pulse oximeter is a device for measuring the pulse as well as the amount, or saturation, of oxygen in the blood. It provides a quick reading without having to do a lab test. Normal O2 saturation levels are 94-99%. Patients with COPD and emphysema will have levels of 90% and higher. Record the level as "SpO2," which indicates that a peripheral reading was obtained. Always notify the nurse of an SpO2 of less than 90%.
Insulin, a hormone, regulates
the amount of sugar in the blood Diabetes is a disease that results when the pancreas does not make enough insulin to decrease or control the amount of sugar in the blood. Clients with diabetes must check their blood sugar levels every day. To stay healthy, they require medication, which can include insulin injections.
Strokes are seen in the elderly. A stroke occurs when
the brain is deprived of oxygen A stroke occurs when the blood supply to the brain is cut off, so oxygen cannot reach the brain cells. Strokes are caused by blood clots in the arteries of the brain or a burst blood vessel in the brain.
The plan that starts on the resident's admission and assists when the resident goes home is called
the discharge plan A good discharge plan allows for continuity of the care that begins on admission. It anticipates possible issues or barriers that the client or the client's family may encounter, and services that will be needed after discharge. All team members can contribute to the plan, based on their interactions with the client.
A Hepatitis B vaccination protects the person receiving it against a disease that affects
the liver Hepatitis B is a serious, contagious infection caused by the hepatitis B virus (HBV). Most commonly spread by exposure to body fluids, it can cause both acute and chronic disease. Many agencies and facilities require employees to receive the HBV vaccination series to protect themselves and others.
A nurse aide is assigned to a stroke patient with a diagnosis of aphasia. The nurse aide knows that
the resident cannot talk When a client has suffered a stroke or some other head injury, the speech center of the brain can be damaged, resulting in aphasia. Chief signs of aphasia include difficulty finding appropriate words when speaking, trouble understanding speech, and difficulty with reading and writing.
A nurse assistant notices red marks on a resident's back and buttocks. The aide acts in the knowledge that
the skin can break down if nothing is done A reddened area is the first sign of skin breakdown. It means that there is pressure and a lack of blood circulation to the area. The nurse aide should immediately reposition the client to eliminate pressure. Clients who are not mobile need to be repositioned at least every two hours. Never massage a reddened area, because this will only increase the damage. Keep the client clean from perspiration, urine, and feces. Continue to observe the skin and report to the nurse if the marks do not quickly disappear.
The opening of the colostomy to the outside of the body is called
the stoma A stoma is an artificial opening in the body, created surgically. To create a colostomy, the surgeon brings the end of the colon through the abdomen and creates a mouthlike opening that will drain waste into a bag. A stoma can also be created for the bladder or the ileum (the lowest part of the small intestine).
A Foley catheter is used
to drain urine from the the bladder A Foley catheter is a sterile tube that is placed into the bladder to drain urine. It is held in place by a balloon that is inflated after being inserted. When a client has an indwelling Foley catheter, you should check that the tubing is open so that the urine can flow from the bladder. After each position change or whenever the client returns to the bed or chair after being up, ensure that the tubing is not kinked or closed. The bag should be lower than the bladder to prevent backflow.
Physical restraints are used MOST often
to prevent client injury Physical restraints are devices or equipment that prevent normal movement. Examples are arm or leg restraints, hand mitts, and vests. It is against the law to use restraints unless they are necessary to treat a client's medical symptoms or there is a risk of harming oneself or others. Restraints may not be used for punishment, convenience, or control. Either a physician's order or the client's consent is required before a restraint can be applied.
The equipment you need for oral care of an unconscious client includes
toothette/mouth swab Because an unconscious client is not able to assist with oral care, you must take extra precautions to prevent the client from choking or aspirating. The client's head should be turned to the side. If possible, lower the head of the bed. Gently clean the teeth and gums with a separate moist toothette or mouth swab for each area of the mouth. When you've finished, wipe the client's mouth and raise the head of the bed to its previous position.
A patient has a diagnosis of psoriasis. Her nurse aide should
treat her the same way as any other patient with a non-infectious disease Autoimmune diseases are never contagious. They happen when the body's immune (defense) system attacks its own healthy tissue by mistake. Besides psoriasis, other autoimmune diseases include lupus, celiac disease, multiple sclerosis, and type 1 diabetes. Client care is the same as for any other client without an autoimmune disease.
To avoid pulling on the catheter while you're turning a male client, the catheter tube must be taped to his
upper thigh An indwelling urinary catheter is used to drain the bladder into a bag outside the body. A catheter for males is a long tube with a balloon that is inflated after being inserted. The tube that drains the urine must not be tugged on or become kinked. In males, it is attached to the client's inner thigh by tape or a special fastening device. Never attach the tube to anything except the client's inner thigh. The drainage bag should remain lower than the client's bladder to prevent a backflow of urine.
The charge nurse has asked you to take Mrs. Shumway's vital signs. Before doing so, you must
wash your hands gather all appropriate equipment identify the patient and introduce yourself Before providing any care, the nurse aide must perform all the standard steps in preparation. ALL the standard steps must be performed before proceeding, not just one. Gather everything you'll need so you won't have to leave the client's room once you begin. Always wash your hands before and after each client interaction. Knocking before entering the client's room, introducing yourself, identifying the client, and explaining what you will be doing are also part of standard practice.
When taking a client's radial pulse, the nurse aide's fingertips should be placed on the client's
wrist A radial pulse is found at the client's wrist. To locate it, place your index and middle fingers on the hollow area below the thumb. Apply light pressure to feel the pulse. Count each beat for 30 seconds and multiply by 2 to get the pulse rate. If the client has an irregular heartbeat, count for 60 seconds. Record the pulse rate on the client's chart.
What should be reported immediately?
A blood pressure of 90/40 Low blood pressure (hypotension) is less than 90/60. Only one of the numbers has to be lower to be considered hypotension. Some clients may have a normal blood pressure in the low range, but if there is a sudden drop from usual, immediately report it to the nurse.
What measurements that you obtained from Mrs. Shumway should be reported immediately to the charge nurse?
B/P 190/114 Hypertension is defined as blood pressure over 140/90. Severe hypertension is above 180/120. Even if the client has a history of high blood pressure, always immediately report a sudden increase to the nurse. Untreated hypertension can lead to heart disease and stroke.
Normal urine color is
yellow Normal urine has a yellow color that ranges from dark yellow to light straw color. Urine that is amber-colored indicates dehydration; more fluids need to be taken. Brown urine can mean severe dehydration or liver disease, and should be checked. Red-tinted urine can occur after the client eats certain foods, such as beets or blueberries. Red urine can also be a sign of kidney disease, urinary tract infection, or prostate problems. Colorless urine may mean that the client is overhydrated and should reduce fluid intake.
For most residents, the range of normal respiration is
12 to 20 inspirations per minute The normal breath rate for adults is 12 - 20 times a minute. When measuring a client's respiratory rate, start when the client is at rest. A single breath comprises one inhalation followed by one exhalation. Count breaths for 60 seconds when taking a respiratory rate.
Mrs. Shumway has an order for I&O. You have picked up her breakfast and note that she drank half of a 6 oz. glass of juice, 4 oz. of milk, and 8 oz. of coffee. Therefore, you document
450 cc The question involves HALF of a 6 oz. glass. 15 oz. = 450 cc. When converting ounces (oz.) to cubic centimeters (cc), remember that 1 oz. = 30 cc. Although an ounce is very slightly less, the amounts are considered equal by doctors and pharmacists. Also, 1 cc = 1 ml.
Your resident consumed a bowl of soup that was 180 cc of liquid. How many ounces was that?
6 oz 180 cc = 6 oz. When converting cubic centimeters (cc) to fluid ounces (oz), remember that 30 cc = 1 ounce. Although an ounce is slightly less, the amounts are considered equal by doctors and pharmacists. Also, 1 cc = 1 ml.
Who can order a warm or cold application?
A doctor It is important to remember that only a doctor can order a treatment, test, or medication for a client. This includes even simple treatments such as hot and cold compresses. A nurse aide can be fired or lose certification for initiating treatments.
Drainage bags from urinary catheters should always
Be kept below the level of the bladder Drainage bags from an indwelling Foley catheter should be kept below the the level of the bladder to prevent urine from backflowing into the bladder. It also allows gravity to help drain the tubing. Always check that the tubing is not kinked or compressed. Depending on the reason for the catheter, urine may have an unusual appearance; ask the nurse what is abnormal for the patient. Monitor and record the color of the urine as well as observations such as sediment, cloudiness, or blood. Follow your facility's policy or the patient's care plan regarding how often to change the urinary drainage bag.
What is the FIRST thing a nurse aide should do when finding an unresponsive client?
Call for help When encountering any type of emergency situation such as an unconscious client, always call for help first. Others can clear the area, phone for an ambulance, assist with CPR, help move or transfer the client, or document the events.
What is the safest way to confirm a resident's identity?
Check the ID bracelet or tag attached to the resident Accurate identification of a resident is always done by checking the resident's ID bracelet or tag. This is a universal standard of practice in every facility and health care setting. It ensures that the resident receives the correct treatment and care every time.
A professional and safe working appearance would include what?
Clean, wrinkle-free uniform; short fingernails; and off-the-shoulder hair The nurse aide is considered a health care professional and should dress accordingly. Each facility has a dress code policy regarding the type of uniform to wear. Clothing must be clean and free from stains, tears, or wrinkles. Shoes must be closed toe with non-skid soles. Appropriate grooming is always necessary. To prevent a nurse aide from injuring a client while giving care, the nurse aide's jewelry is usually limited to a watch and a wedding ring. A name tag is part of the standard uniform.
Signs and symptoms of shock may include
Low blood pressure, tachycardia, clammy, pale skin Signs of shock include low blood pressure (hypotension), a rapid heart rate (tachycardia), a weak pulse, and pale skin which can be damp or clammy. The client may also be breathing rapidly (hyperventilation). The client may also be confused or not alert. Shock is an emergency situation, requiring rapid treatment.
What statement about blindness is false?
Most legally blind or visually impaired people have no sight at all People who are legally blind or visually impaired may still be able to see, but images can be quite blurry even when they're wearing glasses. They have difficulty reading and are restricted from such activities as driving. Another disability results from tunnel vision. A person with this condition can only see straight ahead, lacking the peripheral vision to see almost 180 degrees. Only about 10 - 15% of people who are diagnosed as blind see nothing at all.
You are caring for Mr. Brown, who has a diagnosis of COPD. His SpO2 is 82%. He is currently receiving O2 via Nasal Cannula @ 2 liters/min. What do you do?
Report it STAT to the nurse Ask Mr. Brown to take breaths more frequently. Turn up the O2 to 4 liters/min. The normal SpO2 range for a client with Chronic Obstructive Pulmonary Disease (COPD) is 88-92%. This is because oxygen reaches the lungs but lung damage prevents oxygen from getting into the blood. For clients with COPD, giving oxygen is carefully regulated with limits according to how the oxygen is delivered. Immediately report a low saturation to the nurse. Do not make any changes on your own.
What is the purpose of the chain of command in a long-term care facility?
To keep communication about a problem flowing smoothly Every staff member has a role in providing excellent client care. With good communication, each person can work within their scope of practice and allow others with different authority to handle appropriate tasks. In a long-term care facility, the CNA reports to the registered nurse (RN) or licensed vocational nurse (LVN), who in turn reports to the Director of Nursing. The facility's Administrator and Medical Director may be the persons with the most responsibility.
The electric shaver that the nurse aide is using to shave a client begins to spark and smoke. What should the nurse aide do FIRST?
Unplug the shaver Whenever you give a client care, remember that the patient's safety comes first. Unplug a malfunctioning device to stop sparks or smoke. If the client or anyone nearby is on oxygen, the sparks could trigger a fire, so you may need to move people out of the area quickly. After everyone is safe, notify the nurse of the incident. Never use another client's personal items; this is strictly prohibited because of the risk of infection.
When operating a manual bed, the nurse aide should remember to
fold the cranks under the bed When working a manual bed, first lock the bed by pressing down the levers on the wheels at the head and foot of the bed. At the end of the bed there are three cranks which control the bed height, as well as raising and lowering the head and feet. Cranks are turned clockwise (left to right) to raise each section, and counterclockwise to lower it. After positioning the client, always fold the cranks under the bed to prevent others from tripping or falling.
The circulatory system consists of the
heart, arteries, veins, and capillaries The circulatory system is made up of the heart, arteries, veins, and capillaries. They are connected to make a complete circuit in the body. The heart pumps oxygenated blood from the lungs, as well as nutrients, through the arteries to the capillaries. The capillaries then deliver carbon dioxide and waste to the veins. The veins take the waste products to the liver and kidneys for disposal, and the carbon dioxide goes to the lungs to be exhaled.
Before performing any procedure, a nurse aide must
identify the patient explain the procedure wash his or her hands Clinical standards require all health care professionals to identify the client by checking the ID band or tag before providing care. They should wash their hands both before and after an encounter with a client. They should also explain what they are going to do and give the client an opportunity to ask questions before proceeding.
A resident with an ileostomy evacuates feces through the
ileum The ileum is the lowest part of the small intestine. An ileostomy is an opening in the abdomen that is created during surgery. The end of the ileum is placed outside the body and connected to a bag that collects the waste of the intestine. The ileostomy is usually on the lower right side of the body.
Diabetes mellitus makes a resident more prone to develop
infections Diabetics have high blood sugar levels, which can weaken the immune system, the body's defense system against infections. In diabetes, infections most commonly occur in the urinary tract and skin. Furthermore, diabetics often have nerve damage; they can develop foot infections without realizing it.
When helping a client who is recovering from a stroke to walk, the nurse aide should assist
on the client's weak side When helping a client who is recovering from a stroke to walk, you should stay on the client's weak side. Walk next to and slightly behind the client to be ready to suddenly support the weak side. If the client is using a walker or cane, allow space for the device. While walking, be alert to avoid possible fall hazards. The client should wear slippers or shoes with rubber soles for traction.
If the nurse aide discovers fire in a client's room, the FIRST thing to do is
remove the client The nurse aide should be familiar with all fire safety policies and protocols. If a fire alarm sounds, all staff must respond to keep clients safe. Remember "R.A.C.E." to quickly act. R = Rescue/Remove all people who can not take care of themselves. A = Alarm, if it has not already been done. Pulling the alarm can be done at the same time as rescue. C = Confine/Contain the fire or smoke by closing doors to prevent or slow the spread. Smoke is especially dangerous for everyone. E = Extinguish the fire if possible, using a handheld fire extinguisher. Only try to extinguish small fires and only as long as you can remain safe and have an escape route.
