1.
Ceiling lifts are the only safe patient handling devices that are available at the VA for safe patient handling.
Correct Answer
B. False
Explanation
The given statement is false because it states that ceiling lifts are the only safe patient handling devices available at the VA for safe patient handling. This is not true as there are other safe patient handling devices available apart from ceiling lifts.
2.
HCTs/NAs should participate in the Post Fall Huddle meetings.
Correct Answer
A. True
Explanation
HCTs/NAs should participate in the Post Fall Huddle meetings because these meetings provide an opportunity to discuss and analyze the circumstances surrounding a fall incident. By involving the healthcare team members and nursing assistants, a comprehensive understanding of the factors contributing to the fall can be gained. This allows for the development of appropriate interventions and strategies to prevent future falls and ensure patient safety.
3.
How many staff members are required when using a lift for safe patient handling?
Correct Answer
B. A minimum of 2 people
Explanation
When using a lift for safe patient handling, a minimum of 2 people are required. This is because one person operates the lift while the other person assists in positioning and supporting the patient during the transfer. Having two staff members ensures that the patient is safely lifted and moved without putting excessive strain on any one individual.
4.
Common areas of increased risk for pressure ulcers include all except:
Correct Answer
D. Thighs
Explanation
Pressure ulcers, also known as bedsores, are caused by prolonged pressure on the skin and underlying tissues. Common areas at increased risk for pressure ulcers include bony prominences where there is less subcutaneous fat and muscle padding, such as the elbows, occiput (back of the head), and knees. These areas are more susceptible to pressure and friction. However, the thighs are not considered a common area of increased risk for pressure ulcers as they usually have more subcutaneous fat and muscle, providing better protection against pressure.
5.
Factors that will increase the risk of pressure ulcer development in hospitalized patients are: (select all that apply)
Correct Answer(s)
A. Dry skin
B. Incontinence
C. Spasticity
D. Poor positioning
Explanation
Dry skin, incontinence, spasticity, and poor positioning are all factors that can increase the risk of pressure ulcer development in hospitalized patients. Dry skin can lead to skin breakdown and make the skin more susceptible to pressure ulcers. Incontinence can cause prolonged exposure to moisture, which can weaken the skin and increase the risk of pressure ulcers. Spasticity, which is involuntary muscle contractions, can lead to increased pressure on certain areas of the body and impair blood flow, increasing the risk of pressure ulcers. Poor positioning, such as prolonged immobility or being in a position that puts excessive pressure on certain areas, can also contribute to the development of pressure ulcers.
6.
A patient is experiencing chest pain, the nurse may ask you to perform the following tasks except:
Correct Answer
D. Give nitroglycerin
Explanation
The nurse may ask you to perform tasks such as obtaining vital signs, obtaining an EKG, and obtaining oxygen saturation levels to assess the patient's condition and determine the appropriate course of action. However, giving nitroglycerin is not within the scope of the nurse's responsibilities as it requires a prescription from a healthcare provider.
7.
The hypoglycemia protocal is initiated when a blood sugar of less than ________ is obtained.
Correct Answer
C.
8.
In order to prevent a catheter acquired urinary tract infection (CAUTI), the following interventions can be provided by the CNA/HCT except:
Correct Answer
D. Notify the MD of cloudy or red urine color
Explanation
The CNA/HCT can provide peri care every shift to maintain hygiene and prevent CAUTI. They can also check for signs and symptoms of infection to identify any early indicators. Additionally, they can ensure that there are no kinks in the tubing or coil on the bed to ensure proper flow of urine. However, notifying the MD of cloudy or red urine color is not within the scope of the CNA/HCT's responsibilities as it requires medical expertise and diagnosis.
9.
In order to protect the patient's skin, you can provide the following interventions: (select all that apply)
Correct Answer(s)
A. Bathing
B. Apply barrier cream to reddened areas
C. Limit linen to only 2 layers
Explanation
To protect the patient's skin, several interventions can be provided. Bathing helps to keep the skin clean and free from irritants. Applying barrier cream to reddened areas creates a protective layer and prevents further damage. Limiting linen to only 2 layers reduces friction and irritation on the skin. Placing adult briefs on the patient and changing them every four hours helps to maintain cleanliness and prevent moisture-related skin issues.
10.
I pledge to demonstrate the core values of the American Nurses Association code of ethics by upholding the standards of honesty and integrity. By answering yes, you certify that you are the person taking this test.
Correct Answer
A. Yes
Explanation
The given correct answer is "Yes." This answer indicates that the person taking the test pledges to demonstrate the core values of the American Nurses Association code of ethics by upholding the standards of honesty and integrity. By selecting "Yes," the person certifies that they are the one taking the test.
11.
If a patient is having feeding problems, you should do the following (select all that apply):
Correct Answer(s)
A. Cut meat
B. Butter bread
C. Open packages
D. Remind the patient to eat slowly
Explanation
Patients with feeding problems may have difficulties chewing or swallowing food. Cutting meat into smaller, more manageable pieces can make it easier for them to eat. Buttering bread can help soften it, making it easier to chew and swallow. Opening packages can be helpful for patients who have limited dexterity or strength in their hands. Reminding the patient to eat slowly can prevent them from choking or experiencing discomfort while eating.
12.
The most serious problem that wrinkles in the bedclothes can cause is
Correct Answer
C. Pressure ulcer
Explanation
Wrinkles in the bedclothes can cause pressure ulcers. Pressure ulcers, also known as bedsores, occur when there is prolonged pressure on the skin, leading to damage and breakdown of the skin and underlying tissues. Wrinkles in the bedclothes can create uneven pressure points on the body, particularly in areas with bony prominences such as the hips, heels, and elbows. This can restrict blood flow to the affected areas, leading to tissue damage and the development of pressure ulcers. Restlessness, sleeplessness, bleeding, and shock are not directly caused by wrinkles in the bedclothes.
13.
The most common site for counting the pulse is the
Correct Answer
D. Radial artery
Explanation
The radial artery is the most common site for counting the pulse because it is easily accessible and located close to the surface of the skin. It is located in the wrist, on the thumb side, making it convenient for healthcare professionals to feel and count the pulse. Additionally, the radial artery has a strong and consistent pulse, making it easier to accurately determine the heart rate.
14.
You are helping a spinal cord injury patient with his lunch and suddenly the patient tells you that he has a terrible headache and that he is not feeling right. The patient is sweating profusely. What would be the first action you would take.
Correct Answer
A. Stay with the patient and notify the nurse immediately
Explanation
COG 12-2013 Spinal Cord Injury Treatment Guidelines for Physicians and Nurses
15.
Patients with SCI (spinal cord injuries) can experience episodes of extreme elevated blood pressure. If you are caring for an SCI patient, you should be attentive to the following to prevent an occurrence of extreme blood pressure. Select all that apply:
Correct Answer(s)
A. Allow patient to use his own wheelchair
B. Reposition patient every two hours if in bed
C. Encourage patient activity
D. Check patient clothing that may be tight or constricting.
Explanation
T Drive: Spinal Cord Injury Treatment Guidelines for Physician and Nurses.
16.
According to the F.A.S.T. acronym, which of the following can be signs and symptoms of a stroke. select all that apply:
Correct Answer(s)
A. Sudden weakness
B. Trouble speaking
C. Sudden severe headache
D. Inability to move one side
Explanation
Nursing Protocol: Signs and Symptoms of Acute Ischemic Stroke (ASI)
17.
The nurse has initiated a Rapid Response for a possible stroke for the patient you have been caring for. The registered nurse may ask you to perform the following tasks for the patient, select all the task(s) that you are allowed to perform within your scope of practice.
Correct Answer(s)
A. EKG
B. Place of telemetry
D. Check glucose
Explanation
Nursing Protocol: Signs and Symptoms of Acute Ischemic Stroke (ASI)