Gna Practice Questions II

When repositioning a heavy client, it is important for the nurse aide to prioritize the safety of both the client and themselves. Moving a heavy client alone can put both parties at risk of injury. Therefore, it is recommended for the nurse aide to get another aide to help. This ensures that the client can be moved safely and with proper support, minimizing the risk of accidents or injuries.

The correct answer is to notify the charge nurse of the rash. This is because the nursing assistant has observed a rash on the resident's leg, and it is important to inform the charge nurse so that appropriate action can be taken. The charge nurse can assess the rash, determine the cause, and provide the necessary treatment or consult with a healthcare professional if needed. Ignoring the rash or trying to treat it without proper guidance could potentially worsen the condition or cause harm to the resident.

In this scenario, the correct answer is to allow the client privacy. It is important for the nurse aide to respect the client's privacy and autonomy. Masturbation is a normal and private behavior for many individuals, and the nurse aide should not interfere or make the client feel ashamed or uncomfortable. However, if the client's behavior becomes disruptive or inappropriate in a public setting, it may be necessary to address the situation and report it to the charge nurse.

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 has a low, flat design with a tapered end, which makes it easier for the client to position themselves on the bedpan without causing discomfort or further injury to the hip. It provides better support and stability for the client with a broken hip compared to other types of bedpans such as plastic, pediatric, or metal pans.

Redness is recognized as the first sign of a pressure sore because it indicates that there is increased blood flow to the area. This increased blood flow is a result of tissue damage and inflammation, which can lead to the formation of a pressure sore. Swelling, numbness, and pain may occur later as the pressure sore progresses, but redness is the initial indicator that a pressure sore may be developing.

The correct answer is b. ask the nurse to check the client immediately. This is the most appropriate action to take because a sore spot in the calf could be a sign of a blood clot, also known as deep vein thrombosis (DVT). DVT is a serious condition that requires immediate medical attention, as it can lead to complications such as a pulmonary embolism. Therefore, it is important to involve the nurse to assess the client and determine the appropriate course of action.

In case of a fire, the first priority should always be the safety and well-being of the residents. By attempting to get the resident out of the room and closing the door, the nurse aide can help prevent the fire from spreading and protect the resident from harm. This action also follows the basic protocol of evacuation and containment in case of a fire emergency. Getting the fire extinguisher or removing the resident's cigarettes may be necessary actions later, but the immediate concern should be to ensure the resident's safety. Pulling the fire alarm should be done after ensuring the resident's safety and alerting others in the facility.

The best way to measure accurate daily weights is to weigh the client at the same time and day. This is because weight can fluctuate throughout the day due to factors such as food intake, hydration levels, and clothing. By weighing the client at the same time and day, it helps to minimize these variables and provide a more accurate measurement of their actual weight.

Padded side rails are used to protect the client from injury. They act as a barrier that prevents the client from falling out of bed or getting injured by hitting the hard metal or wooden rails. The padding provides cushioning and reduces the risk of bruises or cuts that could occur if the client accidentally hits or bumps into the rails. This safety measure is particularly important for clients who are at risk of falling or have mobility issues, as it helps to maintain their safety and prevent potential harm.

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 contained and ready to be taken to the laundry for cleaning. Placing it on the bedside table or on the floor would leave it unorganized and potentially create a mess. Placing it in a red plastic bag is not specified as the correct option and may not be the standard procedure in a healthcare setting.

The correct answer is a. airway, breathing, circulation. In emergency care, the ABC's refer to the order of priorities in assessing and treating a patient. Airway comes first, as it is crucial to ensure that the patient's airway is open and clear. Breathing follows, as it is important to assess and support the patient's breathing. Finally, circulation is addressed, focusing on assessing and maintaining the patient's circulation and vital signs. This sequence is essential in providing immediate and life-saving care in emergency situations.

Placing dentures in a labeled denture cup ensures their security because it provides a designated and safe storage space for the client's dentures. This helps prevent them from getting lost or misplaced, as the labeled cup makes it easier to identify and locate the dentures when needed. Additionally, keeping dentures in a cup reduces the risk of damage or breakage that could occur if they were stored in a tissue or drawer.

Residents care about what they wear. This statement suggests that residents have a preference for the clothes they wear and value their personal appearance. It implies that their clothing choices are important to them and should be respected by the nurse aide when assisting with dressing.

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 limitations. Having a desire for companionship and romantic relationships is a natural part of human emotions and experiences. Therefore, it is understandable and expected for a young resident with muscular dystrophy to express this desire.

The items in option c - milk, custard, and soup - 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 primarily composed of water. Custard is also a liquid-based dessert that contains a significant amount of water. On the other hand, options a, b, and d include solid or semi-solid foods that do not contribute to fluid intake as much as the items in option c.

A rash that appears suddenly should be reported immediately to the charge nurse because it could be a sign of an allergic reaction or a contagious skin condition. Prompt reporting allows for timely intervention and prevents the spread of infection or worsening of symptoms.

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 different food items on their plate. This system helps them navigate their meal independently and ensures that they are able to find and eat all the food on their plate.

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 cause the urine bag to appear empty. By checking for kinks, the nurse aide can ensure that the urine is able to flow properly and accurately record the resident's output. Irrigating the catheter, replacing the drainage bag, or replacing the catheter would not address the immediate issue of a potential kink in the tube.

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 from a person's airway. This involves standing behind the person and applying upward pressure to the abdomen, which creates a force that can help expel the object blocking the airway. It is important to call for help first to ensure that additional assistance is available if needed.

Voiding is another term for urination. It refers to the process of emptying the bladder by releasing urine through the urethra. This term is commonly used in medical and clinical settings to describe the act of passing urine. The other options provided in the question are not correct because defecation refers to the process of passing stool, wetting the bed refers to involuntary urination during sleep, and flatus refers to the release of gas from the digestive system.

Nurse aides should wash their hands before going to the bathroom to prevent the spread of germs. This is because they may come into contact with contaminated surfaces or objects in the bathroom, and washing their hands helps to remove any potential pathogens. Washing hands after each client contact, before eating, and after changing dressings are all important practices to maintain proper hygiene and prevent the transmission of infections.

The nursing assistant should tell clients how to call for help because it is important for clients to know how to seek assistance in case of emergencies or when they need help with their healthcare needs. This knowledge empowers clients to take control of their own safety and well-being, ensuring that they can quickly and effectively communicate their needs to the appropriate healthcare professionals.

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 weaker side of the client's body. By starting on the left side, the nurse aide can ensure that the client is comfortable and safe during the dressing process.

When ambulating a client with a Foley catheter, it is important to carry the bag below bladder level. This helps to prevent any backflow of urine into the bladder, which can lead to urinary tract infections. By carrying the bag below bladder level, gravity helps to maintain the flow of urine from the bladder into the bag. This is the safest and most appropriate method for ensuring the proper function of the Foley catheter during ambulation.

The client's lack of bowel movement for five days may indicate constipation, which can lead to nausea as a common symptom. Constipation can cause a buildup of stool in the intestines, leading to discomfort and a feeling of fullness, which can trigger nausea. Additionally, the client's complaint of nausea may be related to the body's attempt to compensate for the lack of bowel movement by increasing digestive secretions, resulting in an upset stomach.

The correct answer is d 120 cc. In the medical field, cc stands for cubic centimeter, which is a unit of measurement commonly used for liquids. One cc is equal to one milliliter, so 120 cc is equivalent to 120 milliliters. The nurse aides would document the client's juice intake as 120 cc to accurately record the amount consumed.

Sputum is best collected upon awakening in the morning because during the night, secretions in the respiratory tract accumulate and are more likely to be present in the sputum. This allows for a more accurate analysis and diagnosis of respiratory conditions such as infections or diseases. Collecting sputum in the morning also ensures that the patient has not eaten or drunk anything that could contaminate the sample, providing a more reliable result.

Being sneezed on can lead to contamination through direct contact because when someone sneezes, respiratory droplets containing potentially harmful microorganisms are released into the air. These droplets can then directly come into contact with another person's body, potentially leading to the transmission of infections or diseases.

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 more difficult 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 effectively communicate with the hearing impaired client.

In this situation, the nurse aide accidentally got blood in her eyes. The first step should be to rinse the eyes out with clear water. This is important to minimize the risk of any potential infection or injury caused by the blood. Rinsing the eyes with water can help to flush out any contaminants and reduce the chances of any harm. It is crucial to address this issue promptly to ensure the nurse aide's safety and well-being.

The vital signs that should be reported immediately are those that are outside of the normal range and indicate a potential medical emergency. In option b, the temperature (T) is significantly low at 95.4, the pulse (P) is low at 40, the respiratory rate (R) is low at 10, and the blood pressure (BP) is low at 80/40. These vital signs suggest hypothermia, bradycardia, bradypnea, and hypotension, which are all abnormal and require immediate attention.

The correct answer is d left Sim's. In a left Sim's position, the patient lies on their left side with the right knee flexed towards the chest. This position allows for better access to the rectum during an enema procedure. The left side positioning helps to promote the flow of the enema solution into the rectum and reduces the risk of complications.

When using client restraints, the nurse aide should observe skin irritation. This is important because restraints can cause pressure points and skin breakdown, leading to irritation or even injury. By regularly monitoring the client's skin, the nurse aide can identify any signs of irritation and take appropriate measures to prevent further harm. This includes repositioning the client, providing skin care, and adjusting the restraints as needed.

Client abuse refers to any intentional harm or mistreatment inflicted upon a client. Options a, b, and c all involve deliberate actions that cause discomfort or distress to the client, such as physically forcing their fingers off the side rail, intentionally keeping the call bell out of their reach, or turning off the light against their wishes. However, using gloves to provide peri-care is not an example of client abuse. In fact, using gloves is a standard practice in healthcare to maintain hygiene and prevent the spread of infection.

The nurse aide should remain with the patient until he finishes smoking because it is important to ensure the safety of the patient. By staying with the patient, the nurse aide can monitor the situation and prevent any potential accidents or harm that may occur while the patient is smoking. Additionally, remaining with the patient shows support and provides a sense of companionship, which can be beneficial for the patient's well-being.

It is important to practice standard precautions when providing oral hygiene because there is a risk of exposure to bodily fluids, such as saliva, during this procedure. Standard precautions include wearing gloves, using protective eyewear, and following proper hand hygiene protocols to prevent the transmission of infections.

The correct answer is c. grasp the belt and lower the client to the floor. When a client becomes weak and begins to fall during a transfer, the nurse's aide should immediately grasp the transfer belt and lower the client to the floor. This action helps to prevent the client from falling and potentially injuring themselves. Calling for help and holding the client tightly might not be the most appropriate initial actions, as they may not effectively prevent the client from falling. Holding the transfer belt and leaning against the wall may also not provide enough support to prevent the client from falling.

The correct answer is c. bedpan. A client who is weak and unsteady may not be able to safely use a commode or toilet without assistance. A bedpan would provide a stable and secure option for the client to use the bathroom without the need for the nurse aide to be present. A urinal may not be suitable for someone who needs to urinate while lying down, as it is designed for use while sitting or standing.

During a seizure, it is important for the nurse aide to protect the client from injuring themselves. Holding the client down may cause harm and restrict their movements. Putting a tongue depressor in their mouth is not recommended as it can cause further injury. Running out of the room to get help may leave the client unattended and at risk. Therefore, the best course of action is to ensure the client's safety by protecting them from any potential harm during the seizure.

Reality orientation techniques are used to help individuals with cognitive impairments stay oriented to their surroundings and maintain a sense of reality. This can include labeling items in the client's room, putting up calendars and clocks to help them keep track of time, and using familiar items in their room to provide a sense of familiarity. However, reminding a client that their spouse is deceased does not fall under the category of reality orientation techniques. This can be emotionally distressing and may not be helpful in maintaining their sense of reality.

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 capable of walking independently. Restraining the resident or placing them in a locked room would be a violation of their rights and could potentially cause harm. Walking with the resident may not be necessary unless they require assistance or supervision. Therefore, the nurse aide should continue to observe the client to ensure their safety and well-being while they are walking in the hall.

In this scenario, the client's inability to speak and clutching her neck suggest that she may be choking. Therefore, the nurse aide should first perform the Heimlich maneuver, which is a technique used to dislodge an obstruction from a person's airway. This action can help to clear the client's airway and restore their ability to breathe.

The correct answer is c. thinking that the CIA is secretly watching him. This is an example of a client's delusion because it involves a false belief that is not based on reality. Delusions are often characterized by irrational or unfounded beliefs that are not shared by others. In this case, the client believes that they are being watched by the CIA, which is a paranoid and irrational belief.

The nurse aide must use a stethoscope to determine the apical pulse rate because the apical pulse is measured by listening to the heart sounds using a stethoscope. 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. This method provides a more accurate measurement of the pulse rate compared to other pulse sites like the carotid, popliteal, or brachial pulse.

To place a client in good alignment, the nurse aide should keep the client's straight as possible. This means ensuring that the client's body is positioned in a straight line, with their head, neck, spine, and extremities aligned properly. This helps to maintain proper body mechanics and prevent strain or injury to the client. Keeping the client straight also promotes proper circulation and breathing.

When forcing fluids, the nurse aide should offer fluids every hour. This is because forcing fluids refers to the act of encouraging and ensuring that a patient consumes an adequate amount of fluids to maintain hydration. By offering fluids every hour, the nurse aide ensures a consistent intake and helps prevent dehydration. It is important to note that the type of fluids offered may vary depending on the patient's condition and medical orders.

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 ensure that she is using the correct muscles and avoiding any potential injuries. This method also allows for better balance and stability while changing direction.

Transferring a client from a bed to a stretcher requires that the nurse aide use proper body mechanics. This means using the correct posture and technique to ensure the safety of both the nurse aide and the client. Proper body mechanics involve maintaining a straight back, bending at the knees, and using the strength of the legs instead of the back to lift and move the client. This helps to prevent strain and injury to the nurse aide's back and ensures a smooth and safe transfer for the client.

Option c. is the correct answer because it shows empathy and understanding towards the client's emotions. By asking her if she is upset with her doll, the nurse aide acknowledges and validates her feelings, allowing the client to express herself and potentially uncover any underlying concerns or emotions. This approach promotes effective communication and provides an opportunity for the nurse aide to address the client's needs appropriately.

The nurse aide should position the wheelchair at the side of the bed, facing the foot of the bed. This positioning allows for easier transfer of the client from the bed to the wheelchair. Placing the wheelchair at the foot of the bed or at the head of the bed would make it more difficult for the client to move from the bed to the wheelchair.