Advanced Certified Nursing Assistant Practice Test!

When repositioning a heavy client, it is important for the nurse aide to prioritize the safety of both the client and themselves. Attempting to move the client alone may put both parties at risk of injury. Allowing the family to move the client may not be appropriate as they may not have the necessary training or knowledge to do so safely. Therefore, the best option is to get another aide to help, as this ensures that the task can be completed safely and efficiently.

The correct answer is to notify the charge nurse of the rash. This is important because the nursing assistant is responsible for the resident's well-being and any changes in their condition should be reported to the charge nurse. The rash could be a sign of an underlying medical condition or an adverse reaction to medication, so it is important to inform the charge nurse so that appropriate action can be taken. Ignoring the rash or attempting to treat it without proper guidance could potentially worsen the resident's condition.

Padded side rails are used to protect the client from injury. They act as a barrier to prevent the client from falling out of bed or getting trapped between the bed and the rail. The padding helps to cushion any impact and reduce the risk of injury if the client accidentally hits the rail. This safety measure is particularly important for clients who are at risk of falls or have mobility issues.

In this situation, it is important for the nurse aide to respect the client's privacy and autonomy. Masturbation is a normal and private behavior, and it is not the nurse aide's role to interfere or judge the client. Instead, the nurse aide should provide the client with privacy and maintain a professional and non-judgmental attitude. Reporting the incident to the charge nurse may not be necessary unless there are specific concerns for the client's safety or well-being.

The best way to measure accurate daily weights is to weigh the client at the same time and day. This ensures consistency and eliminates variables that could affect the weight measurement, such as clothing or meals. By weighing the client at the same time and day, healthcare professionals can obtain reliable and comparable daily weight measurements, which are important for monitoring changes in fluid status or body mass.

The nurse aide should first check for kinks in the tube. This is important because a kink in the tube can obstruct the flow of urine and prevent it from draining into the bag. By checking for kinks, the nurse aide can ensure that the urine is able to flow freely and that the Foley catheter is functioning properly. If there are no kinks in the tube, then other possible causes for the empty urine bag can be explored.

Placing dentures in a labeled denture cup is the correct answer because it ensures the security of the client's dentures. By using a labeled denture cup, the dentures are kept in a designated and easily identifiable container, reducing the risk of misplacement or confusion. This method also helps to maintain the cleanliness and hygiene of the dentures, as they are protected from dust and other contaminants. Additionally, a labeled denture cup allows for easy identification and retrieval of the client's dentures, promoting efficient and organized care.

The correct answer is "residents care about what they wear." This statement implies that residents have a preference for the clothes they wear and want to have a say in their dressing choices. It acknowledges the importance of respecting their autonomy and individuality in deciding what to wear.

The correct answer is to ask the nurse to check the client immediately. This is the best course of action because a sore spot in the calf could potentially be a sign of a more serious condition such as a blood clot or muscle tear. It is important to involve the nurse to assess the client's condition and provide appropriate medical intervention if necessary. Massaging the legs with lotion, having the client walk, or assessing the soreness every hour may not address the underlying cause of the sore spot and could potentially worsen the condition.

The first sign of a pressure sore is redness. This is because pressure on the skin can cause decreased blood flow to the area, leading to tissue damage. The redness is an early indication that the skin is not receiving enough oxygen and nutrients, and if left untreated, it can progress to a pressure sore or ulcer. It is important for the nurse aide to recognize this early sign and take appropriate measures to relieve pressure and prevent further damage.

When dressing a client with left-sided weakness, it is important for the nurse aide to begin dressing him on the left side. This is because the client's left side is weaker, so starting on the left side allows the nurse aide to provide support and assistance to the client as needed. By starting on the left side, the nurse aide can ensure that the client is comfortable and safe during the dressing process.

The nursing assistant should tell clients how to call for help because it is important for clients to know how to reach out for assistance in case of emergencies or when they need immediate medical attention. This knowledge can ensure their safety and well-being, allowing them to receive timely help when needed.

Unconscious clients may be able to hear you speak to them during the bath. This is because hearing is one of the last senses to go when a person becomes unconscious. Even though they may not be able to respond or communicate, it is important to talk to them in a soothing and reassuring manner during the bath. This can help provide comfort and a sense of familiarity to the client.

In case of a fire, the safety of the resident should be the nurse aide's first priority. Attempting to get the resident out of the room and closing the door is the correct action to take. This helps to contain the fire and prevent it from spreading to other areas of the facility. It also ensures that the resident is moved to a safe location away from the fire.

When making a bed, the nurse aide should place the soiled linen in a laundry bag. This is the correct answer because a laundry bag is specifically designed to hold dirty or soiled linens and is used to transport them to the laundry room for cleaning. Placing the soiled linen on the bedside table or on the floor would be unhygienic and can spread germs. Using a red plastic bag is not mentioned as a standard practice for handling soiled linens in healthcare settings.

The ABC's of emergency care stand for airway, breathing, and circulation. This mnemonic is used to prioritize the steps in providing immediate care to someone in a life-threatening situation. It emphasizes the importance of ensuring that the person's airway is clear, that they are breathing properly, and that their circulation is adequate. By addressing these three vital functions first, healthcare providers can maximize the chances of saving a person's life in an emergency situation.

When using client restraints, it is important for the nurse aide to observe for any signs of skin irritation. Restraints can cause pressure points and restrict blood flow, which can lead to skin breakdown and irritation. By regularly observing the client's skin, the nurse aide can identify any potential issues and take appropriate action to prevent further complications. This ensures the client's safety and well-being while using restraints.

It is important for nurse aides to wash their hands before going to the bathroom to prevent the spread of germs and maintain hygiene. Washing hands before each client contact, before eating, and after changing dressings are all necessary to prevent the transmission of infections and maintain a safe and clean environment for both the nurse aide and the clients.

The items that would be included in fluid intake are those that contain a significant amount of liquid. Milk, custard, and soup are all examples of foods that have a high liquid content and can contribute to fluid intake.

A client with a broken hip would require a fracture pan for an enema. A fracture pan is specifically designed with a low profile and a flat front to accommodate individuals with limited mobility or those who cannot flex their hips. This type of pan helps to minimize discomfort and prevent further injury to the client's hip during the enema procedure. Plastic, pediatric, and metal pans may not provide the necessary support and positioning required for a client with a broken hip.

The nurse aides would document the client's juice intake as 120 cc because cc stands for cubic centimeter, which is a metric unit of volume commonly used in the medical field. In this case, the client consumed four ounces of juice, which is equivalent to 120 cc.

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Voiding is another name for urination. It refers to the act of emptying the bladder by releasing urine through the urethra. This term is commonly used in medical and healthcare settings to describe the process of eliminating waste fluids from the body.

A rash that appears suddenly needs to be reported immediately to the charge nurse because it could be a sign of an allergic reaction or an infection. It may require immediate medical attention or intervention to prevent further complications.

The nurse's aide's first action should be to grasp the belt and lower the client to the floor. This is the safest and most appropriate response in a situation where the client is weak and beginning to fall. By grasping the belt and lowering the client to the floor, the nurse's aide can prevent further injury and ensure the client's safety. Holding the transfer belt and leaning against the wall may not provide enough support to prevent the client from falling. Calling for help is important, but it should be done after taking immediate action to prevent the client from falling. Holding the client tightly may not be effective in preventing a fall and could potentially cause harm to the client.

Visually challenged clients use a "clock" system to find their food. This means that they mentally divide their plate into sections like a clock and use their sense of touch to locate and eat their food. This technique helps them navigate their plate independently and ensures that they can eat their meal without assistance.

When a resident begins to choke and is unable to speak, the nurse aide should call for help and begin doing abdominal thrusts. Abdominal thrusts, also known as the Heimlich maneuver, involve applying pressure to the abdomen to forcefully expel the blockage and clear the airway. This technique is effective in dislodging the obstruction and allowing the resident to breathe again. Mouth-to-mouth ventilation would not be appropriate in this situation as the resident is still conscious and able to breathe partially. Back blows and a finger sweep are also not recommended as they may further obstruct the airway.

The vital signs T-95.4, P-40, R-10, BP-80/40 should be reported immediately because they indicate a low body temperature (T-95.4), a low pulse rate (P-40), a low respiration rate (R-10), and a low blood pressure (BP-80/40). These vital signs suggest that the individual may be experiencing a medical emergency, such as shock or hypovolemia, and immediate medical attention is required.

The feeling of wanting a boyfriend is best described as normal because it is a common desire for many young individuals, regardless of their physical condition or disability. It is natural for people to seek companionship and emotional connection, and having muscular dystrophy does not make this desire any less valid or normal.

When providing postmortem care, it is important for the nurse aide to wear gloves. This is because gloves help to prevent the spread of any potential infections or diseases that may be present on the deceased person's body. Wearing gloves also helps to maintain proper hygiene and cleanliness during the care process. Additionally, gloves provide a barrier between the nurse aide's hands and any bodily fluids or substances that may be encountered while providing care. Therefore, wearing gloves is an essential precautionary measure in postmortem care.

In this situation, the client's inability to speak and clutching of her neck suggests that she may be choking. The Heimlich maneuver is a technique used to clear a person's airway when they are choking. It involves applying pressure to the abdomen to force air out of the lungs and dislodge the obstruction. Therefore, performing the Heimlich maneuver would be the most appropriate and immediate action to take in order to help the client.

Sputum is best collected upon awakening in the morning because during the night, secretions accumulate in the respiratory tract. This makes it easier to produce a good quality sputum sample for analysis. Collecting sputum in the morning also helps to minimize contamination from food or other substances that may have been ingested during the day. Additionally, collecting sputum in the morning allows for a more accurate diagnosis of respiratory conditions as it reflects the overnight accumulation of secretions.

Before ambulating a client who has a Foley catheter, the nurse aide should carry the bag below bladder level. This is important because if the bag is positioned above the level of the bladder, urine may flow back into the bladder, increasing the risk of infection. By carrying the bag below bladder level, gravity helps to maintain proper drainage and prevent any backflow of urine. This is the safest and most appropriate action to ensure the client's comfort and minimize the risk of complications.

When caring for a hearing impaired client, the nursing assistant should do all of the following except raise their voice. This is because raising the voice does not necessarily improve the client's ability to hear and understand. Instead, the nursing assistant should stand or sit facing the client, speak clearly and softly, and use simple words and sentences to effectively communicate with the hearing impaired client.

The correct answer is left Sim's. Left Sim's position is the ideal position for a patient to receive an enema. In this position, the patient lies on their left side with the left leg straight and the right leg bent. This position allows for easy access to the rectum and facilitates the flow of the enema solution. It also helps to prevent discomfort and leakage during the procedure.

During a seizure, it is important for the nurse aide to protect the client from injuring themselves. This can be done by removing any objects that may cause harm, such as sharp objects or furniture, and creating a safe environment. The nurse aide should also ensure that the client's head is protected and cushioned to prevent any head injuries. Restraining the client or putting a tongue depressor in their mouth is not recommended, as it can potentially cause harm or injury. Running out of the room to get help may delay immediate assistance that the client may need during the seizure.

Reality orientation techniques are used to help individuals with cognitive impairments stay connected to reality and maintain a sense of time, place, and identity. Labeling items in the client's room, putting up calendars and clocks, and using familiar items in the client's room are all examples of reality orientation techniques that can help individuals with memory loss or confusion. However, reminding a client that his spouse is deceased is not a reality orientation technique. It may be emotionally distressing and can potentially worsen their confusion or disorientation.

In this situation, the nurse aide accidentally gets blood in her eyes, which can potentially lead to infection or transmission of diseases. The immediate action should be to rinse the eyes out with clear water to flush out any contaminants and reduce the risk of infection. This is a simple and effective first aid measure that can be done quickly before seeking further medical attention or reporting the incident to the charge nurse.

Standard precautions are a set of infection control practices that healthcare workers follow to prevent the spread of infection. These precautions include using personal protective equipment (such as gloves and masks), practicing proper hand hygiene, and safely handling and disposing of contaminated materials. When providing oral hygiene to a patient, there is a risk of exposure to bodily fluids, such as saliva and blood, which may contain infectious agents. Therefore, it is important to practice standard precautions during this procedure to minimize the risk of transmission of infections.

The nurse aide should remain with the patient until he finishes smoking because it is important to ensure the safety of the patient and prevent any potential accidents or incidents that may occur while smoking unsupervised. By staying with the patient, the nurse aide can monitor the situation and intervene if necessary. This approach promotes responsible and safe smoking practices within the facility.

The client's lack of bowel movement for five days could be indicative of constipation, which can cause a variety of symptoms including nausea. When stool builds up in the intestines, it can lead to discomfort and bloating, which may trigger feelings of nausea. The other listed symptoms such as headache, leg cramps, and chest pain could also be associated with constipation, as the body may experience overall discomfort and tension. It is important to address the client's constipation and relieve it to alleviate the accompanying symptoms.

A client who is weak and unsteady may not have the strength or stability to safely use a commode or toilet without assistance. Therefore, the nurse aide should provide a bedpan, which can be used while the client remains in bed. This ensures the client's safety and prevents the risk of falls or injuries. A bedpan allows the client to urinate without having to get up or move, which is especially important for those who are weak or unsteady.

The nurse aide should keep the client's straight as possible in order to place them in good alignment. This means ensuring that the client's body is properly aligned and positioned, with the spine straight and the limbs in a neutral position. This helps to prevent any strain or discomfort on the client's joints and muscles, and promotes proper posture and body mechanics. Keeping the client straight as possible also helps to maintain proper body alignment while performing activities such as transferring or repositioning the client.

The correct answer is to continue to observe the client. Restraining the resident may not be necessary or appropriate if they are able to walk safely. Walking with the resident may not be feasible for the nurse aide if they have other responsibilities. Placing the resident in a locked room is not an appropriate or ethical solution. Therefore, the best course of action is for the nurse aide to continue observing the client to ensure their safety and well-being.

The nurse aide should offer fluids every hour because forcing fluids means encouraging the patient to drink fluids frequently in order to maintain hydration and promote proper bodily functions. Offering fluids every hour ensures that the patient is consistently receiving an adequate amount of fluids throughout the day. It is important to note that the type of fluids offered may vary depending on the patient's condition and dietary restrictions.

Being sneezed on can lead to possible contamination through direct contact because when someone sneezes, respiratory droplets containing germs are released into the air. If these droplets come into direct contact with a person, they can easily transfer the germs and potentially cause infection or illness.

To change direction, a nurse aide should turn her whole body by moving her feet. This is the correct answer because it is the safest and most efficient way to change direction while maintaining balance and stability. By turning the whole body and using the feet to pivot, the nurse aide can ensure proper alignment and prevent strain or injury to the back or waist. Twisting from the waist or moving the body in sections can lead to poor body mechanics and potential harm. Moving the body very slowly may not be necessary unless there is a specific reason to do so.

Transferring a client from a bed to a stretcher requires the nurse aide to use proper body mechanics. This means using the correct posture, body alignment, and techniques to prevent injury to themselves and the client. By using proper body mechanics, the nurse aide can minimize the strain on their muscles and joints and ensure a safe and effective transfer. The other options, such as a Hoyer Lift, a minimum of three coworkers, or a mobility mattress, may be helpful in certain situations, but they are not the primary method for transferring a client in this scenario.

The nurse aide must use a stethoscope to determine the apical pulse rate. The apical pulse is measured by placing the stethoscope on the chest over the apex of the heart. This allows the nurse aide to listen to the heart sounds and count the number of beats per minute. The apical pulse rate is an important indicator of cardiac function and can provide valuable information about a patient's health.

The nurse aide should position the wheelchair at the side of the bed, facing the foot of the bed. This positioning allows for a smooth transfer of the client from the bed to the wheelchair. Placing the wheelchair at the side of the bed ensures that the client can easily slide or pivot from the bed onto the wheelchair. Facing the foot of the bed allows the client to have their back towards the head of the bed, making it easier for them to sit down in the wheelchair.