CNA Practice Exam III

The correct answer is to notify the charge nurse of the rash. This is the appropriate action to take because the nursing assistant is not qualified to diagnose or treat medical conditions. The charge nurse can assess the rash and determine the appropriate course of action, such as notifying the resident's healthcare provider or applying a topical treatment. It is important to report any changes or abnormalities in a resident's condition to the charge nurse to ensure their health and well-being.

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. Letting the family move the client may not be feasible or appropriate in all situations. Moving the client later may cause discomfort or potential complications. Therefore, the best course of action is to get another aide to help, ensuring that the client is repositioned safely and effectively.

Padded side rails are used to protect the client from injury. These rails provide a soft cushioning effect, reducing the risk of the client hitting or injuring themselves against the hard side rails of the bed. They act as a barrier, preventing the client from falling out of bed or getting trapped between the rails. Padded side rails are commonly used in healthcare settings to ensure the safety and well-being of the clients.

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 weaker 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 help the client maintain balance and stability while dressing, ensuring their safety and comfort throughout the process.

To measure accurate daily weights, it is important to weigh the client at the same time and day. This ensures consistency and eliminates any variations that may occur due to factors like food intake or clothing. Weighing the client without clothing or fully clothed can lead to inaccurate measurements as it does not provide a consistent baseline. Weighing the client after breakfast can also be misleading as food intake can affect weight. Therefore, weighing the client at the same time and day is the best approach for accurate daily weight measurements.

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 is respecting their autonomy and dignity. It is not necessary to insist the client stop or ask why they are engaging in this behavior. Reporting it to the charge nurse may not be necessary unless there are specific concerns or issues related to the client's well-being or safety.

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. Therefore, it is important for the nurse aid to ask the nurse to check the client immediately. This will ensure that the client receives appropriate medical attention and any necessary interventions can be implemented promptly.

Residents care about what they wear. This suggests that residents have a preference for their clothing and want to have a say in what they wear. It acknowledges the importance of respecting their autonomy and individuality in the dressing process.

The nurse aide should first check for kinks in the tube. This is important because kinks in the tube can obstruct the flow of urine, preventing it from reaching the urine bag. By checking for kinks and ensuring that the tube is properly aligned and free from obstructions, the nurse aide can ensure that the urine can flow freely into the bag. This is a simple and non-invasive step that should be taken before considering any other interventions such as irrigating the catheter or replacing the drainage bag or catheter.

To ensure the security of a client's dentures, it is important to place them in a labeled denture cup. This helps in keeping the dentures safe and easily identifiable. Storing them in a tissue in a dresser drawer may lead to misplacement or damage. Insisting the client wear the denture does not guarantee security when the dentures are not in use. Placing an identifying mark on the dentures can be helpful, but it is not as effective as placing them in a labeled denture cup for easy identification and protection.

When using client restraints, the nurse aide should observe skin irritation. This is important because restraints can cause skin damage and irritation if not properly monitored. By observing the client's skin, the nurse aide can identify any signs of irritation such as redness, swelling, or pressure sores. This allows for early intervention and prevention of further skin damage. It is crucial for the nurse aide to regularly check the client's skin while using restraints to ensure their safety and well-being.

The first sign of a pressure sore is redness. This can indicate that there is increased pressure on a specific area of the body, which can lead to tissue damage and the formation of a pressure sore. Redness is often the earliest sign of a pressure sore and should be addressed immediately to prevent further complications. Swelling, numbness, and pain may also be present in later stages of a pressure sore, but redness is typically the initial indicator.

The nursing assistant should tell clients how to call for help because it is important for clients to know how to alert the healthcare team in case of emergencies or when they need assistance. This information empowers clients to take control of their own care and ensures that they can receive prompt help when needed. It is a crucial aspect of patient safety and well-being.

The correct answer is a. airway, breathing, circulation. In emergency care, the ABC's refer to the order of priorities when assessing and providing initial treatment to a patient. Airway refers to ensuring that the patient's airway is clear and unobstructed. Breathing involves assessing and assisting the patient's breathing if necessary. Circulation refers to evaluating and maintaining the patient's circulation, including checking for a pulse and controlling any bleeding. This order of priorities is crucial in ensuring the patient's survival and preventing further harm.

In the event 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 helps to contain the fire and prevent it from spreading further. This action also ensures the resident's immediate safety by removing them from the source of danger. Once the resident is safe, the nurse aide can then proceed to alert others and take further necessary actions such as pulling the fire alarm or using a fire extinguisher if trained to do so.

When providing postmortem care, wearing gloves is essential to prevent the spread of infectious diseases and to maintain proper hygiene. The nurse aide must protect themselves and others from potential bodily fluids or contaminants that may be present during the care process. Wearing gloves helps to minimize the risk of cross-contamination and ensures the safety and well-being of both the nurse aide and the deceased individual.

The correct answer is d left Sim's. In a left Sim's position, the patient lies on their left side with their left leg straight and their right leg bent. This position allows for easy access to the rectum for the administration of an enema. The left side positioning helps to facilitate the flow of the enema solution into the rectum and colon, promoting effective evacuation.

The correct answer is c. milk, custard, soup. These items would be included in fluid intake because they are all liquid or semi-liquid substances that contain water. Milk and soup are obvious choices as they are liquid in nature. Custard is a semi-liquid dessert made with milk and eggs, so it also contributes to fluid intake. The other options (a, b, and d) include solid food items that do not count as fluid intake.

Unrination is another term for the process of voiding, which refers to the act of emptying the bladder by releasing urine. The other options provided in the question are incorrect. Defecation refers to the act of emptying the bowels, wetting the bed refers to involuntary urination during sleep, and flatus refers to the release of gas from the digestive system. Therefore, the correct answer is b. voiding.

A client with a broken hip needs an enema, and the best bedpan to use would be a fracture pan. This is because a fracture pan is specifically designed with a low, flat profile and a handle to make it easier for patients with limited mobility or injuries, such as a broken hip, to use. The low profile allows the patient to slide onto the pan without lifting their legs too high, reducing discomfort and potential further injury. The handle provides stability and support for the patient while using the pan.

The correct answer is d) 120 cc. The nurse aides would document the client drinking four ounces of juice as 120 cc because 1 ounce is equivalent to 30 cc. Therefore, four ounces would be 4 x 30 = 120 cc.

Nurse aides should wash their hands in all situations except before going to the bathroom. Washing hands before going to the bathroom is not necessary because the purpose of handwashing is to remove germs and prevent the spread of infection. Since the nurse aide will be using the bathroom for personal hygiene purposes, there is no need to wash hands before entering. However, it is important for them to wash their hands after using the bathroom to ensure proper hygiene and prevent the transmission of any potential pathogens.

It is important to speak to unconscious clients during the bath because even though they may not be able to respond or show signs of hearing, research suggests that they may still have some level of auditory awareness. Speaking to them can provide a sense of comfort and reassurance.

Visually challenged clients use a "clock" system to find their food. This means that they mentally divide their plate into sections, similar to the numbers on a clock, and use their sense of touch to locate and identify different food items on their plate. This system helps them navigate their meal independently and accurately.

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 first aid technique used to dislodge an obstruction in the airway. This involves standing behind the person and using upward pressure on the abdomen to force air from the lungs and dislodge the object. It is important to call for help first because if the obstruction is not cleared, the person may become unconscious and require further assistance.

The vital signs that should be reported immediately are those that fall outside of the normal range and indicate a potential medical emergency. In option b, the temperature (T) is significantly lower than the normal range, the pulse (P) is lower than normal, the respiratory rate (R) is lower than normal, and the blood pressure (BP) is significantly lower than the normal range. These abnormal vital signs suggest that the patient may be experiencing hypothermia and hypotension, which require immediate medical attention.

When transferring a client, if the client becomes weak and begins to fall, the nurse's aide's first action should be to grasp the transfer belt and lower the client to the floor. This action is important to prevent any further injury to the client and ensure their safety. Holding the transfer belt allows the nurse's aide to have control and support while guiding the client down to the floor gently. It is important to prioritize the client's safety and well-being in such situations.

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 proper containment and prevents the spread of germs and bacteria. It also makes it easier for the laundry staff to collect and transport the soiled linen for cleaning. Placing the soiled linen on the bedside table or on the floor would be unhygienic and could potentially contaminate other surfaces. Using a red plastic bag is not specified or necessary, so the correct option is to place the soiled linen in a laundry bag.

This question asks for an example of client abuse that is NOT included in the given options. Option d, using gloves to provide peri-care, is not an example of client abuse. Using gloves is a standard protocol for hygiene and infection control, and it is necessary to protect both the client and the caregiver from potential pathogens. Therefore, option d is the correct answer.

In this scenario, the client is clutching her neck and unable to speak, which suggests that she may be choking. The Heimlich maneuver is a technique used to clear a blocked airway and is the appropriate response in this situation. Calling for help is important, but performing the Heimlich maneuver should be done first to immediately address the choking and potentially save the client's life. Offering her a drink of water or hitting her on the back may not be effective in dislodging the obstruction and could potentially worsen the situation.

Standard precautions are a set of infection control practices that healthcare workers follow to prevent the spread of infections. These precautions include hand hygiene, using personal protective equipment, safe handling and disposal of sharps, and respiratory hygiene. When providing oral hygiene to a patient, healthcare workers come into contact with saliva, which can contain microorganisms. Therefore, practicing standard precautions during oral hygiene procedures is important to prevent the transmission of infections from the patient to the healthcare worker or vice versa.

A rash that appears suddenly should be reported immediately to the charge nurse because it could indicate an allergic reaction or an infectious condition that requires immediate attention. It is important to identify the cause of the rash and provide appropriate treatment to prevent further complications.

The nurse aide should remain with the patient until he finishes smoking because it is important to ensure the patient's safety while they are smoking. By staying with the patient, the nurse aide can monitor the situation and take immediate action if any issues arise. This also helps to prevent any potential accidents or harm that may occur if the patient smokes unsupervised.

Sputum is best collected upon awakening in the morning because during the night, secretions accumulate in the respiratory tract. This is because the body is in a resting position and the cilia, which help in clearing the respiratory tract, are less active during sleep. Therefore, collecting sputum in the morning provides a higher chance of obtaining a good sample for analysis, as it contains a higher concentration of pathogens or abnormal cells that may be present in respiratory infections or diseases.

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 disability. It is a natural part of human development and social interaction to seek companionship and romantic relationships. Having muscular dystrophy does not diminish one's longing for emotional connection and intimacy, making this feeling completely understandable and typical.

To prevent backflow of urine and ensure proper drainage, it is important to carry the Foley catheter bag below bladder level. This helps to maintain the flow of urine from the bladder into the bag and prevents any potential complications or discomfort for the client. It is not necessary to clamp off or disconnect the catheter before ambulating the client, as long as the bag is carried below bladder level. Letting the bag dangle between the client's legs or hiding it in a pillow case are not appropriate actions and may lead to complications or discomfort for the client.

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 improve the client's ability to hear, but instead may distort the sound and make it more difficult for the client to understand. It is important for the nursing assistant to 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 client's lack of bowel movement for five days could indicate constipation or a potential blockage in the digestive system. This can lead to the accumulation of waste and toxins in the body, causing nausea as a common symptom. Headaches, leg cramps, and chest pain are less directly related to the client's bowel movement issue and may have other underlying causes.

During a seizure, it is important to protect the individual from injuring themselves. Holding them down may cause further harm and restraining them could lead to injuries. Putting a tongue depressor in their mouth is not recommended as it can cause damage to the teeth or airway. Running out of the room and getting help is not the appropriate action as the nurse aide should stay with the client and provide support until the seizure ends. Therefore, the best course of action is to protect the client from injuring themselves during the seizure.

Reality orientation techniques are used to help individuals with cognitive impairments stay connected to reality and maintain their sense of time, place, and identity. These techniques involve strategies such as labeling items in the client's room, putting up calendars and clocks to provide a sense of time, and using familiar items in the client's room to create a sense of familiarity. However, reminding a client that his spouse is deceased is not a reality orientation technique. This statement can be distressing and may not help the client maintain their connection to reality.

The correct answer is b. keep the clients straight as possible. This is because maintaining good alignment is important for the client's overall comfort and well-being. By keeping the client's body straight, the nurse aide can help prevent any unnecessary strain or pressure on the client's joints and muscles. This can also help promote proper circulation and prevent the development of pressure ulcers.

The correct answer is d. continue to observe the client. This is because the resident is walking back and forth in the hall, which may indicate agitation or restlessness. By continuing to observe the client, the nurse aide can monitor their behavior and ensure their safety. Restraint should only be used as a last resort, and placing the resident in a locked room may be considered a form of restraint. Walking with the resident may not be necessary if they are able to walk independently and safely.

Transferring a client from a bed to a stretcher requires the nurse aide to use proper body mechanics. This means using correct posture, body alignment, and techniques to protect their own body from strain or injury while safely moving the client. Using proper body mechanics helps to distribute the weight and force evenly, reducing the risk of musculoskeletal injuries for both the nurse aide and the client. It also ensures a smooth and efficient transfer, maintaining the client's comfort and safety.

In this situation, the nurse aide should first rinse her eyes out with clear water. This is important because blood may contain harmful pathogens or infectious agents that can cause eye infections or other health issues. By rinsing her eyes with clear water, she can help to minimize the risk of infection and potential harm to her eyes. It is crucial to prioritize immediate action to ensure her safety and well-being.

The nurse aide cannot safely leave a weak and unsteady client alone to use a commode or a toilet as they may not have the strength or balance to sit or stand without assistance. Similarly, a urinal may not be suitable for a client who is weak and unsteady as it requires them to be in a standing position. Therefore, the safest option would be to provide a bedpan for the client, as it can be used while they are lying down and eliminates the risk of falls or injuries.

Being sneezed on can result in direct contact with respiratory droplets containing infectious particles, which can lead to contamination. Sneezing releases a large number of droplets that can travel through the air and land on surfaces or be inhaled by others in close proximity. This direct contact can easily transmit pathogens and potentially cause infection. Cleaning a bedpan, touching used linens, and using a doorknob can also lead to contamination, but they involve indirect contact rather than direct contact like being sneezed on.

When forcing fluids, the nurse aide should offer fluids every hour. This is because forcing fluids refers to the act of encouraging or increasing fluid intake in a patient, typically to prevent dehydration or promote hydration. Offering fluids every hour ensures a regular and consistent intake of fluids throughout the day, helping to maintain proper hydration levels.

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. Twisting from the waist or moving the body in sections can lead to strain or injury, while moving the body very slowly may not be practical in a fast-paced healthcare environment. Moving the feet allows for a smooth and controlled change in direction.

The nurse aide must use a stethoscope to determine the apical pulse rate because the apical pulse is the most accurate measurement of the heart's contractions. It is located at the apex of the heart, which is the point where the heartbeat can be heard most clearly. Using a stethoscope allows the nurse aide to listen to the sounds produced by the heart and count the number of beats per minute, providing an accurate measurement of the apical pulse rate.

The client is displaying behavior that suggests she may be upset or distressed with her doll. By asking her if she is upset with her doll, the nurse aide can assess the client's emotional state and potentially address any concerns or provide comfort if needed. This response shows empathy and a willingness to understand the client's feelings.