Certified Nursing Assistant Practice Exam 5 Learning Express

When repositioning a heavy client, it is important for the nurse aide to prioritize the safety and well-being of both the client and themselves. Attempting to move the client alone may put both parties at risk of injury. Letting the family move the client may not be feasible or appropriate in all situations. Therefore, the best course of action is to get another aide to help. This ensures that the client is moved safely and effectively, minimizing the risk of injury for both the client and the nurse aide.

The correct answer is to notify the charge nurse of the rash. This is because the nursing assistant is responsible for the resident's care and well-being, and noticing a rash could indicate a potential health issue. By notifying the charge nurse, the nursing assistant ensures that appropriate action can be taken, such as assessing the rash, providing necessary treatment, or involving other healthcare professionals if needed. Ignoring the rash, washing it, or rubbing it with alcohol may not address the underlying cause or provide appropriate care for the resident.

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 injured by hitting the hard edges of the bed frame. The padding provides cushioning and reduces the risk of bruises, cuts, or fractures that could occur if the client were to accidentally hit or bump into the rails. Overall, padded side rails are an important safety measure in healthcare settings to ensure the well-being and protection of the client.

The ABC's of emergency care stand for airway, breathing, and circulation. This acronym is used to prioritize the steps that need to be taken during emergency situations. Airway refers to ensuring that the person's airway is clear and unobstructed. Breathing involves checking for the person's breathing and providing any necessary assistance. Circulation focuses on assessing the person's circulation and taking appropriate measures to maintain blood flow. These three steps are crucial in providing immediate and life-saving care to individuals in emergency situations.

It is important to speak to unconscious clients during the bath because they may still be able to hear you. Even though they are unconscious, their sense of hearing can still be active. Speaking to them can provide reassurance and comfort, as well as help maintain a sense of connection and dignity.

The nurse aide should first check for kinks in the tube. This is because a kink in the tube can prevent urine from flowing into the bag, causing it to appear empty. By checking for kinks, the nurse aide can ensure that the urine is able to flow properly and accurately record the output of the resident. This is a simple and non-invasive action that can help troubleshoot the issue before considering other interventions such as irrigating the catheter or replacing the drainage bag or catheter.

The correct answer is a. before going to the bathroom. Nurses aides should wash their hands before and after each client contact to prevent the spread of infections. They should also wash their hands before eating to maintain proper hygiene. Additionally, they should wash their hands after changing dressings to prevent contamination. However, washing hands before going to the bathroom is not necessary as the purpose of handwashing is to prevent the transmission of germs and not to protect oneself from germs in the bathroom.

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 starting on the left side allows the nurse aide to provide support and assistance to the client's weaker side. By starting on the left side, the nurse aide can ensure that the client is comfortable and safe during the dressing process.

If a resident begins to choke while being fed 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, are a technique used to clear a blocked airway by applying pressure to the abdomen in an upward motion. This can help dislodge the object causing the choking and allow the person to breathe again. It is important to call for help first to ensure that additional assistance is available if needed.

The correct answer is d. using gloves to provide peri-care. This answer is correct because using gloves to provide peri-care is not an example of client abuse. Using gloves is a standard practice to maintain hygiene and prevent the spread of infections during peri-care procedures. The other options listed, such as forcing clients' fingers off the side rail, deliberately leaving the call bell out of reach, and turning the light out against the client's wishes, are all examples of client abuse as they violate the client's rights and well-being.

The first sign of a pressure sore is redness. This is because pressure sores, also known as bedsores or pressure ulcers, occur when there is prolonged pressure on a specific area of the skin. The pressure restricts blood flow to that area, leading to tissue damage. Redness is an early indication that the skin is not receiving enough blood flow and oxygen, and if left untreated, it can progress to more severe stages of pressure sores. Swelling, numbness, and pain may occur later as the condition worsens.

Visually challenged clients use a "clock" system to find their food. This means that they mentally divide their plate into sections, similar to the face of a clock, and use this system to locate different items of food on their plate. This method helps them to navigate and eat their meals independently, without the need for assistance.

Reality orientation techniques are used to help individuals with cognitive impairments stay connected to reality and maintain a sense of time, place, and person. This includes labeling items in the client's room, putting up calendars and clocks, and using familiar items. However, reminding a client that his spouse is deceased is not a reality orientation technique. This reminder can be distressing and may not contribute to the individual's overall well-being or sense of reality.

In this situation, it is important for the nurse aide to respect the client's privacy. Masturbation is a normal and natural behavior, and it is not the nurse aide's role to interfere or judge the client. By allowing the client privacy, the nurse aide promotes autonomy and dignity, ensuring that the client feels comfortable in their own space. Additionally, reporting the incident or insisting that the client stop may violate the client's rights and could potentially harm the therapeutic relationship between the nurse aide and the client.

A client with a broken hip needs an enema, and the best bedpan to use would be a fracture pan. A fracture pan is specifically designed with a low, flat profile, which makes it easier for the client to position themselves on it without causing discomfort or further injury to their hip. The low height of the fracture pan also reduces the risk of falls or additional strain on the client's hip during the process. Therefore, using a fracture pan is the most suitable option in this scenario.

Placing the client's dentures in a labeled denture cup ensures their security. This method allows for easy identification and prevents the dentures from getting misplaced or mixed up with others. Keeping them in a tissue in a dresser drawer or insisting the client wear the denture does not provide the same level of security and may result in loss or damage. Placing an identifying mark on the dentures may be helpful, but it is not as effective as using a labeled denture cup.

Sputum is best collected upon awakening in the morning because during sleep, mucus and secretions accumulate in the respiratory tract. This makes the sputum sample more representative of the patient's condition and increases the chances of detecting any abnormalities or pathogens present in the respiratory system. Collecting sputum in the morning also allows for a higher concentration of the sample, making it easier for laboratory analysis and diagnosis.

The term "voiding" is another name for urination. It refers to the act of emptying the bladder by releasing urine. This term is commonly used in medical and healthcare settings to describe the process of urination. "Defecation" refers to the elimination of feces, "wetting the bed" refers to involuntary urination during sleep, and "flatus" refers to the passing of gas. Therefore, the correct answer is b. voiding.

In this situation, the client is clutching her neck and unable to speak, indicating that she may be choking. The Heimlich maneuver is a technique used to dislodge an obstruction from the airway and restore breathing. Therefore, performing the Heimlich maneuver would be the most appropriate first action to take in order to help the client.

In this situation, the nurse aide's immediate concern should be to rinse her eyes out with clear water. This is because blood can carry various pathogens and potential infections, and rinsing the eyes can help minimize the risk of any potential harm. Calling 911 may not be necessary unless there are severe symptoms or complications. Reporting the incident to the charge nurse and documenting it should be done after the immediate action of rinsing the eyes to ensure proper documentation and follow-up procedures are followed.

When using client restraints, the nurse aide should observe skin irritation. This is important because restraints can cause pressure ulcers, skin breakdown, and other skin irritations. By regularly checking the client's skin, the nurse aide can identify any signs of irritation and take appropriate measures to prevent further complications.

If a client complains of a sore spot in her calf, it could be indicative of a potential issue such as a blood clot or muscle strain. Asking the nurse to check the client immediately is the most appropriate action because it ensures that the client receives timely and appropriate medical attention. This allows for prompt assessment and intervention to address the underlying cause of the sore spot and prevent any potential complications.

A rash that appears suddenly should be reported immediately to the charge nurse because it could be a sign of an allergic reaction or an infectious disease. Prompt reporting is necessary to ensure that appropriate measures are taken to address the rash and prevent any potential complications.

To measure accurate daily weights, it is important to weigh the client at the same time and day. This helps to minimize variations caused by factors such as food intake, hydration levels, and clothing. Weighing the client without clothing or fully clothed can introduce additional variables that may affect the accuracy of the measurements. Therefore, weighing the client consistently at the same time and day provides a more reliable and consistent measure of their weight.

The correct answer is c. milk, custard, soup. These items would be included in fluid intake because they are all liquid or have a high liquid content. Milk and soup are obvious sources of fluids, while custard is a creamy dessert that contains milk and liquid ingredients.

When making a bed, the nurse aide should place the soiled linen in a laundry bag. This is the correct answer because placing the soiled linen in a laundry bag ensures that it is properly contained and can be easily transported to the laundry room for cleaning. This helps maintain cleanliness and hygiene in the patient's room. Placing the soiled linen on the bedside table or on the floor would be unhygienic and could potentially spread germs. Using a red plastic bag is not specified as the correct method for handling soiled linen.

Residents care about what they wear. This statement suggests that residents have a preference or concern about the clothes they wear, indicating that their clothing choices are important to them. This implies that dressing is not just a practical necessity, but also a way for residents to express their personal style or maintain a sense of dignity and self-esteem.

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 may distort the sound and make it harder for the client to understand. Instead, the nursing assistant should stand or sit facing the client, speak clearly and softly, and use simple words and sentences to ensure effective communication.

It is important to practice standard precautions when providing oral hygiene because oral care involves direct contact with the patient's mouth and can expose healthcare providers to potential pathogens present in saliva or oral secretions. Standard precautions include using personal protective equipment such as gloves and masks, as well as proper hand hygiene before and after providing oral hygiene to prevent the transmission of infections.

The nurse aide must use a stethoscope to determine the apical pulse rate. The apical pulse is the heartbeat heard at the apex of the heart, which is located at the fifth intercostal space at the midclavicular line. Using a stethoscope allows the nurse aide to listen to the heart sounds and count the number of beats per minute accurately. This method is commonly used in healthcare settings to assess the heart rate and rhythm of patients.

The client is described as weak and unsteady, indicating that they may have difficulty walking or maintaining balance. Therefore, it would be unsafe to leave them alone to use a commode or a toilet, as they may fall or injure themselves. A bedpan would be the most appropriate option as it can be used while the client is lying down in bed, ensuring their safety and preventing any accidents. A urinal may also be an option, but it may not be suitable for someone who is weak and unsteady as it requires them to be in a seated or standing position.

The nursing assistant should tell clients how to call for help because it is important for their safety and well-being. In case of any emergencies or situations where they require assistance, knowing how to call for help ensures that they can quickly and effectively communicate their needs to the appropriate personnel. It empowers clients to take control of their own safety and enables them to receive timely assistance when needed.

The correct answer is d. continue to observe the client. This is because the resident is walking back and forth in the hall, which indicates that they are mobile and able to move around independently. Restraining the resident or placing them in a locked room would be a violation of their rights and unnecessary unless there is a safety concern. Walking with the resident may not be necessary if they are able to walk on their own. Therefore, the best course of action is for the nurse aide to continue observing the client to ensure their safety and well-being.

To change direction, a nurse aide should turn her whole body by moving her feet. This is the correct answer because it is important for a nurse aide to maintain proper body mechanics and avoid twisting or straining the waist. By turning the whole body and moving the feet, the nurse aide can maintain stability and prevent injury while changing direction. Moving the body in sections or moving slowly may not provide the same level of stability and can increase the risk of injury.

In a situation where a nurse aid finds smoke and flames coming from a resident's room, the first priority should be the safety of the resident. Attempting to get the resident out of the room and closing the door is the most appropriate action to take. This helps to ensure that the resident is removed from immediate danger and prevents the fire from spreading further. It is important to prioritize the safety and well-being of the resident before taking any other actions such as using a fire extinguisher or pulling the fire alarm.

The client's lack of bowel movement for five days and complaint of nausea suggests that they may be experiencing constipation. Constipation can cause a buildup of stool in the intestines, leading to discomfort and nausea. The other symptoms mentioned (headache, leg cramps, chest pain) are not directly related to constipation and may have different underlying causes.

The feeling of wanting a boyfriend is best described as normal because it is a common desire for many individuals, regardless of their physical condition or circumstances. It is natural for a young person to have romantic aspirations and seek companionship. Having muscular dystrophy does not diminish one's desire for love and connection. Therefore, it is normal for this resident to express their wish for a boyfriend.

When providing postmortem care, wearing gloves is essential to maintain proper hygiene and prevent the spread of infection. Handling a deceased person's body can expose the nurse aide to bodily fluids and other potentially infectious materials. Wearing gloves acts as a barrier, protecting the nurse aide from direct contact with these substances and reducing the risk of contamination. It is a standard precaution that should be followed during postmortem care to ensure the safety and well-being of both the nurse aide and the deceased individual.

The correct answer is b. keep the clients straight as possible. This is because maintaining good alignment helps prevent deformities and promotes proper functioning of the body. Keeping the client straight as possible helps to maintain the correct positioning of the spine and joints, reducing the risk of contractures and pressure ulcers. It also helps to ensure proper breathing and circulation.

The nurse's aide's first action should be to grasp the transfer belt and lower the client to the floor. This is the safest and most appropriate action to take in order to prevent the client from falling and potentially injuring themselves. Holding the transfer belt provides stability and control, while lowering the client to the floor ensures their safety. Calling for help may be necessary, but it should not be the first action taken. Holding the client tightly may cause discomfort or injury to the client and should be avoided.

The vital signs that should be reported immediately are those that fall outside the normal range and indicate a potential medical emergency. In option b, the temperature (T) of 95.4°F is significantly below the normal range, the pulse (P) of 40 beats per minute is very low, the respiratory rate (R) of 10 breaths per minute is also very low, and the blood pressure (BP) of 80/40 mmHg is significantly below the normal range. These abnormal vital signs suggest a potential critical condition and should be reported immediately for further evaluation and intervention.

The nurse aide should position the wheelchair at the side of the bed, facing the foot of the bed, in order to help the client into the wheelchair. This positioning allows for easy transfer from the bed to the wheelchair, as the client can simply slide across from the bed onto the wheelchair seat. Placing the wheelchair at the side of the bed also ensures that the client is facing the correct direction when seated in the wheelchair, ready to be moved.

The correct answer is d left Sim's. In order to receive an enema, the patient should be positioned in left Sim's position. This position involves lying on the left side with the left leg straight and the right leg flexed. The left arm is placed behind the body, and the upper body is slightly inclined forward. This position allows for easy insertion of the enema tube and helps to facilitate the flow of the enema solution into the rectum.

The correct answer is c fluids every hour. When forcing fluids, the nurse aide should offer fluids every hour. This is important to ensure that the patient stays hydrated and to promote proper fluid balance in the body. Offering fluids every hour helps to prevent dehydration and maintain adequate hydration levels. It also allows for regular intake of fluids throughout the day, which is essential for overall health and well-being.

During a seizure, it is important for the nurse aide to protect the client from injuring themselves. This can be done by clearing the area around the client of any objects that may cause harm, such as sharp objects or furniture. The nurse aide should also try to cushion the client's head and remove any restrictive clothing that may impede their breathing. It is important to never restrain or hold down the client during a seizure, as this can potentially cause harm. Additionally, putting a tongue depressor in the client's mouth is not recommended, as it can lead to injury. Running out of the room to get help should only be done if the client's safety cannot be ensured alone.

The nurse aide should remain with the patient until he finishes smoking because it is important to ensure his safety and prevent any potential accidents or harm that could occur while smoking unsupervised. This way, the nurse aide can monitor the patient and intervene if necessary.

The correct answer is c. carry the bag below bladder level. When ambulating a client with a Foley catheter, it is important to ensure that the drainage bag is positioned below the level of the bladder. This helps to prevent backflow of urine into the bladder and reduces the risk of infection. By carrying the bag below bladder level, gravity helps to maintain the proper flow of urine and prevents any potential complications.

Transferring a client from a bed to a stretcher requires the nurse aide to use proper body mechanics. This means using correct posture, body positioning, and techniques to protect both the client and the nurse aide from injury. By using proper body mechanics, the nurse aide can ensure that they are using their muscles efficiently and effectively, reducing the risk of strain or injury. This also helps to maintain the client's comfort and safety during the transfer process. Using a Hoyer lift, having a minimum of three coworkers, or using a mobility mattress are not specifically required for transferring a client from a bed to a stretcher.

This answer is correct because it describes a delusion, which is a fixed false belief that is not based in reality. Thinking that the CIA is secretly watching him is an example of a delusion because it is a belief that is not supported by evidence or reality. Delusions are often associated with psychiatric disorders such as schizophrenia.

The nurse aides would document the client drinking four ounces of juice as 120 cc. Cc stands for cubic centimeters, which is a unit of measurement commonly used in healthcare settings. One cc is equal to one milliliter, so 120 cc is equivalent to 120 milliliters, which is approximately equal to four ounces. Therefore, option d is the correct answer.