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Clients with osteoarthritis may be on bed rest for prolonged periods. The nursing assistant is aware that she should:
encourage coughing and deep breathing and limit fluid intake.
provide only passive range of motion, and decrease stimulation.
have the client lie as still as possible, and give adequate massage.
turn the client every 2 hours, and encourage coughing and deep breathing.
Question 1 Explanation:
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.
Justine (CNA) was instructed by the staff nurse to elevate the client’s casted left limb to prevent swelling. Justine is elevating the casted extremity correctly when she does which of the following?
Places the casted limb above the level of the heart.
Places the casted limb close to the body.
Places the casted limb below the level of the heart.
Places the casted limb at the level of the heart.
Question 2 Explanation:
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.
A nurse obtains 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 safety knot in the restraint straps.
Restraint straps that are safely secured to the side rails.
Jacket restraint straps that do not tighten when force is applied against them.
Jacket restraint secured so that two fingers can slide easily between the restraint and the client’s skin.
Question 3 Explanation:
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.
The nurse inserts a Foley catheter to relieve a client's urinary retention. Which of the following is an inappropriate action in caring for clients with an indwelling catheter?
Emptying the drainage bag every 6-8 hours.
Attaching the drainage bag to the lowest part of the siderails near the client’s feet.
Keeping the drainage bag below bladder level.
Positioning the tubing without dependent loops.
Question 4 Explanation:
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.
Elderly patients 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?
Colas and sodas
Question 5 Explanation:
Cauliflower is gas-forming. Other examples of gas-forming foods are beans, cabbage, radishes, and cucumbers.
In preparing a client for a hot Sitz bath, the nurse assistant should check the temperature of the water. The ideal water temperature is:
Between 105°F and 120°F
Between 95°F and 110°F
Between 80°F and 93°F
Between 65°F and 80°F
Question 6 Explanation:
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.
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:
30 minutes after meals and at bedtime
30 minutes before meals and at bedtime
Question 7 Explanation:
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.
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?
Tactfully refuse the delegated task because you are limited in changing dressings on your own.
After the wound has been cleansed, apply clean dressings and tape completely around the edges of the bandage.
In cleansing the wound, start from the surrounding skin towards the wound in longitudinal strokes.
In changing a dressing, always note the color, odor, amount, and consistency of the drainage on the old dressing.
Question 8 Explanation:
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 is correct about ostomy care?
It is done under sterile technique.
It needs doctor’s order for changing of ostomy pouches.
Able clients can perform this procedure by themselves once they have been taught by the nurse.
The client can still defecate normally.
Question 9 Explanation:
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.
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:
applies the stockings while the client is on bed.
applies the stockings while the client is sitting on the chair.
applies the stockings while the client is sitting on the bed and dangles her feet.
applies the stockings while the client is standing.
Question 10 Explanation:
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 aware that the purpose of the elastic stockings is to:
prevent blood clots.
hold dressings in place.
reduce swelling after injury.
prevent pressure sores.
Question 11 Explanation:
Elastic stockings exert pressure on the veins. The pressure promotes venous blood flow to the heart. By doing so, the stockings prevent blood clots.
A COPD client recently admitted to the floor needs constant oxygen therapy. When assisting this patient, the nursing assistant can:
turn the oxygen on and off.
start the oxygen.
decide what device to use.
keep the connecting tubing secure and free of kinks.
Question 12 Explanation:
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.
After applying an elastic bandage to a client's right leg, you need to check the color and temperature of the leg:
every 15 minutes.
every 2 hours.
Question 13 Explanation:
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.
Which of the following statements is correct pertaining to binders application?
A breast binder can be applied for breastfeeding mothers to relieve discomfort.
Straight abdominal binders are applied when the client is sitting on a chair.
The double T-binder is specifically used for male clients.
When securing a straight abdominal binder, help the client in a side-lying position to close it at the back using safety pins.
Question 14 Explanation:
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.
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?
Question 15 Explanation:
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.
Clients requiring oxygen therapy should be monitored for hypoxia. Early signs for hypoxia include:
Breathing comfortably only when sitting.
Restlessness, dizziness, and disorientation.
Cyanosis and increased pulse rate.
Increased temperature and decreased respiratory rate.
Question 16 Explanation:
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.
An asthmatic client can be relieved from dyspnea when he is placed in orthopneic position. This can done by:
placing the head of bed in 90° angle.
sitting up and leaning over a table with a pillow.
hyper-extending the neck while on high back rest.
placing the client on a high back rest using a pillow.
Question 17 Explanation:
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.
Which action is incorrect when flossing the client’s teeth?
Hold the floss between the middle fingers of each hand.
Make sure you also floss the back side of the very last tooth on the right, left, top, and bottom of the mouth.
Move the floss gently up and down between the teeth.
Use a new piece of floss for each tooth.
Question 18 Explanation:
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.
To obtain a 24-hour urine specimen, the nurse assistant should:
Collect each voiding in separate containers for the next 24 hours.
Discard the first voided specimen and then collect the total volume of each voiding in 24 hours.
For the next 24 hours, retain a 30ml specimen of each voiding after recording the amount voided.
Keep a record of the time and amount of each voiding for 24 hours.
Question 19 Explanation:
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.
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:
Question 20 Explanation:
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.
One of your clients just had a stroke and is manifesting receptive aphasia. Clients with receptive aphasia:
are unable to speak.
have no difficulty in understanding spoken or written language.
are not able to express themselves meaningfully through speech.
speak very loudly at all times.
Question 21 Explanation:
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.
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?
Inform the nurse that the client has voided or defecated.
Do not document at all since it cannot be measured.
Record on the output side of the I&O sheet each time the bed is wet.
Review the client’s intake and record the same amount on the output side of the I&O sheet.
Question 22 Explanation:
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.
Which of the following are examples of fluid output that need to be recorded on the I&O sheet?
Urine and blood loss.
Urine, blood loss, and excessive perspiration.
Urine, emesis, blood loss, and excessive perspiration.
Question 23 Explanation:
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.
A client is receiving oxygen therapy via face mask. Which of the following is contraindicated for this client?
Eating his lunch.
Use of cotton bedclothes.
Shaving using an electric razor.
Talking with visitors.
Question 24 Explanation:
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.
Use of which of the following articles or types of clothing would help a client with osteoarthritis perform activities of daily living adequately?
Tied shoes to promote stability.
Velcro clothing, slip-on shoes, and rubber grippers.
Buttoned clothing, slip-on shoes, and rubber grippers.
Question 25 Explanation:
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.
Which of the following is not included in the care of clients with a pacemaker?
The client is not allowed to be around electrical appliances.
The client can operate a microwave.
The client should avoid magnetic wands in airports.
Cellular phone use should be monitored closely.
Question 26 Explanation:
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.
Your client has had a bowel movement. The stool is black in color and has a tarry consistency. What is your next action?
Ask the client what her previous meal contained.
Ask the nurse to observe the stool.
Dispose of the stool and report the color to the nurse.
Ask a co-worker if this is normal for this client.
Question 27 Explanation:
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.
Which is NOT a rule for collecting specimens?
Follow the rules of medical asepsis.
Use the correct container.
Label the container accurately.
Collect the specimen when you have time.
Question 28 Explanation:
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 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?
Question 29 Explanation:
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 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?
Cover the hole with tape.
Report to the nurse immediately.
Disconnect the drainage bag from the catheter and replace it with a new bag.
Place a towel under the bag to prevent spillage of urine on the floor, which could cause the client to slip and fall.
Question 30 Explanation:
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.
Which of the following methods should be used to collect a specimen for urine culture?
Have the client void in a clean container.
Clean the foreskin of the penis of uncircumcised men before specimen collection.
Have the client void into a urinal, and then pour the urine into the specimen container.
Have the client begin the stream of urine in the toilet and catch the urine in a sterile container midstream.
Question 31 Explanation:
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.
The nursing assistant is correctly providing penile hygiene to an unconscious clients if she:
uses warm water without soap.
dries all areas of the penis thoroughly.
washes from the base of the shaft to the tip.
avoids retracting the foreskin if not circumcised.
Question 32 Explanation:
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).
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?
Dispose of the equipment after each use.
Wear gloves while handling the equipment.
Use only the equipment with other clients in airborne isolation.
Leave the equipment in the room for use only with that client.
Question 33 Explanation:
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.
To prevent circulatory impairment in an arm when applying an elastic bandage, which of the following methods is best?
Wrap the bandage around the arm loosely.
Apply the bandage while stretching it slightly.
Apply heavy pressure with each turn of the bandage.
Start applying the bandage at the upper arm and work toward the lower arm.
Question 34 Explanation:
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.
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?
Question 35 Explanation:
180 + 60 + 240 + 50 = 530 ml
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?
To inhibit drainage.
To allow drainage to occur.
To allow the urine to collect in the tubing.
To have the client check the tubing for urine.
Question 36 Explanation:
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.
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?
Don't allow him to leave his room.
Remove all sharp and cutting objects.
Give him the opportunity to ventilate his feelings.
Stay with him at all times.
Question 37 Explanation:
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.
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?
Focusing on the emotional reaction.
Clarifying the meaning of his statement.
Giving him step-by-step directions.
Doing the procedure for him.
Question 38 Explanation:
The client is experiencing an inability to recognize or name objects (agnosia) and needs single step instructions. Provide verbal connections about using implements.
When the nursing assistant identifies a client who has attempted to commit suicide, the nursing assistant should:
call a priest.
counsel the client.
report immediately to the nurse.
refer the matter to the police.
Question 39 Explanation:
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 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?
Have get-well cards sent anonymously.
Provide paper and pen for letter writing to his sons.
Spend time with him after work hours.
Leave him alone to allow for meditation.
Question 40 Explanation:
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.
Clients and families have the right to receive care that is:
determined necessary by the health team.
culturally acceptable to them.
dictated as appropriate by medical research.
technologically advanced and inexpensive.
Question 41 Explanation:
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.
When caring for a dying client, the nurse aide should perform which of the following activities?
Encourage the client to reach optimal death.
Assist the client to perform activities of daily living.
Assist client towards a peaceful death.
Motivate client to gain independence.
Question 42 Explanation:
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.
When a terminally ill client assumes artificial cheerfulness and refuses to believe that loss is happening, what stage of grieving is he in?
Question 43 Explanation:
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.
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?
Beans and tortillas.
Cheese and olive oils.
Vegetables and rice.
Red meat and potatoes.
Question 44 Explanation:
Food preferences for Hispanic clients often include beans and tortillas. These foods are a staple in the Hispanic diet.
Which of the following techniques would you use when interviewing a 94-year-old patient?
Using a low-pitched voice.
Enunciating each word slowly.
Varying voice intonations.
Reinforcing the words with pictures.
Question 45 Explanation:
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.
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?
“I’m sorry, I don’t know.”
“I’m sure it’s nothing to worry about. You look fine to me.”
“I don’t have any information as of the moment, but I’ll find out for you.”
“You need to ask your doctor about that, not me.”
Question 46 Explanation:
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?
"I’ll be back in an hour."
"Why are you so depressed?"
"I’ll sit with you for a moment."
"Call me when you feel like talking to me."
Question 47 Explanation:
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.
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?
“Don’t say you are worthless, you are not a worthless person.”
“We are going to help you with your feelings.”
“What makes you feel you’re worthless?”
“What you say is not true.”
Question 48 Explanation:
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.
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?
Allow all the client’s family members to stay with the client.
Have conversation at the bedside directed to the client.
Keep the television or radio on for the client continuously.
Keep the overhead light on at all times.
Question 49 Explanation:
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.
Legally, clients’ charts are:
Owned by the government since it is a legal document.
Owned by the doctor in charge and should be kept from the administrator for whatever reason.
Owned by the hospital and should not be given to anyone who requests it other than the doctor in charge.
Owned by the client and should be given by the nurse to the client as requested.
Question 50 Explanation:
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 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?
Question 51 Explanation:
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.
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?
Enroll in a refresher course.
Undergo a retraining and a new competency evaluation.
Competency evaluation only.
No other requirements are required. Just present letter of intent to the Board to go back to work.
Question 52 Explanation:
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.
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?
Ask the nurse to demonstrate it to you for a clearer and better understanding of the procedure.
As assistant to the nurse, follow the nurse’s request and apply the ointment to the patient's eyes.
Ask the nurse to be with you during the application of the ointment.
Politely refuse the nurse’s request and explain your job limitations as a nursing assistant.
Question 53 Explanation:
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.
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:
Use terms with many meanings.
Be brief and concise.
Present information logically and in sequence.
Give facts and be specific.
Question 54 Explanation:
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.
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?
Ask the caller what telephone number he is trying to reach.
Ask the caller to “Please hold, an operator will get to you shortly”, then go back to unfinished tasks.
Refer the call to the nurse on duty. The nurse will transfer the call herself.
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.
Question 55 Explanation:
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 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:
Immediately walk out of the client’s room and answer the phone call.
Cover the client, place the call light within reach, and answer the phone call.
Finish the bed bath before answering the phone call.
Leave the client’s door open so the client can be monitored and the nurse aide can answer the phone call.
Question 56 Explanation:
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.
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:
Nursing discharge summary
Question 57 Explanation:
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.
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?
“It is most likely that the client attempted to climb over the side rails and fell.”
“Upon entering the room, the client was found lying on the floor.”
“The client had been restless all evening and was trying to get out of bed.”
“The presence of a bed alarm could have prevented the fall.”
Question 58 Explanation:
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 action by a nurse aide could jeopardize the confidentiality of computerized medical records available at a nurse’s station?
Log out and sign off all computer screens before leaving a terminal.
Share passwords for computer access with colleagues who have forgotten their own passwords.
Periodically change computer access passwords.
Prevent an unidentified healthcare worker from viewing computer records.
Question 59 Explanation:
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.
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:
speak loudly and slowly.
stand close to the client and speak slowly.
use an interpreter to speak to the client.
speak to the client and family together to increase the chances that the topic will be understood.
Question 60 Explanation:
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.
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