Nursing Assistant Exam 5 Learning

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 the best option as they may not have the necessary training or knowledge to do so safely. Therefore, the best course of action would be to get another aide to help. This ensures that there is enough manpower and expertise to safely reposition the heavy client without risking injury.

The nursing assistant should notify the charge nurse of the rash because it is important to report any changes in a resident's condition, such as the presence of a rash. The charge nurse can then assess the rash and determine the appropriate course of action, such as contacting a healthcare provider or providing treatment. Ignoring the rash or attempting to treat it without proper guidance can potentially worsen the condition or lead to complications.

If a client complains of a sore spot in her calf, it could be a sign of a serious condition such as a blood clot or deep vein thrombosis. Therefore, it is important for the nurse aid to ask the nurse to check the client immediately. This is necessary to ensure the client's safety and to rule out any potential serious complications. Massaging the legs with lotion, having the client walk, or assessing the soreness every hour would not address the potential underlying issue and may delay appropriate medical intervention.

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 consistently weighing the client at the same time and day, any variations caused by these factors can be minimized, resulting in more accurate weight measurements.

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, especially for those who may have difficulty with mobility or may be at risk of rolling out of bed. The padding helps to cushion any impact and reduce the risk of injury if the client were to accidentally hit or bump into the side rails. Overall, padded side rails provide a safety measure to ensure the client's well-being and prevent potential harm.

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 for engaging in this behavior. By allowing the client privacy, the nurse aide is respecting their autonomy and promoting a sense of dignity. 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.

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 remain empty. By checking for kinks, the nurse aide can ensure that the urine is able to flow freely from the resident's bladder into the bag. If there are no kinks in the tube, then the nurse aide can proceed to consider other possible causes for the empty urine bag.

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 that side allows for better support and assistance during the dressing process. By starting on the left side, the nurse aide can ensure that the client is comfortable and stable throughout the dressing procedure.

Placing the client's dentures in a labeled denture cup is the correct answer because it ensures the security of the dentures. By using a labeled denture cup, it becomes easier to identify and locate the dentures when needed. It also helps prevent mix-ups or confusion with other clients' dentures. Additionally, storing the dentures in a denture cup protects them from damage or loss, as compared to keeping them in a tissue in a dresser drawer or insisting the client wear them. Placing an identifying mark on the dentures may also be helpful, but it is not as secure as using a labeled denture cup.

The first sign of a pressure sore is redness. This is because when there is prolonged pressure on a particular area of the body, it can cause damage to the skin and underlying tissues. This damage leads to reduced blood flow to the area, resulting in redness. If left untreated, the pressure sore can progress and become more severe, causing pain and potentially leading to infection. Therefore, it is important for the nurse aide to recognize redness as an early sign and take appropriate measures to prevent further damage.

The nursing assistant should tell clients how to call for help because it is important for clients to know how to seek assistance when they need it. This ensures their safety and well-being in case of emergencies or any other situations where they require immediate help or support. By providing clients with the knowledge of how to call for help, the nursing assistant empowers them to take control of their own health and ensures that they can quickly and effectively communicate their needs to the appropriate personnel.

Residents care about what they wear. This statement implies that residents have a preference and concern for their clothing choices. It suggests that their clothing is not simply a practical necessity but also a means of self-expression and maintaining a sense of personal identity. This understanding is important for caregivers to consider when assisting residents with dressing, as it allows them to respect and accommodate the residents' preferences and individuality.

When using client restraints, the nurse aide should observe skin irritation. This is because the use of restraints can cause pressure on the skin, leading to skin irritation or even pressure ulcers. By regularly observing the client's skin, the nurse aide can identify any signs of irritation or damage and take appropriate measures to prevent further complications. This ensures the client's safety and well-being while using restraints.

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 bacteria from the hands, and the bathroom is not typically a source of contamination. However, it is important to wash hands after each client contact, before eating, and after changing dressings to prevent the spread of infections and maintain proper hygiene.

The items in option c, milk, custard, and soup, would be included in fluid intake because they all contain a significant amount of liquid. Milk and soup are obvious sources of fluid, while custard is made with milk and therefore also contributes to fluid intake. The items in the other options, such as ham sandwich, ice cream bar, mashed potatoes, gelatin, orange juice, soft boiled eggs, and toast, may contain some liquid but are not primarily fluid sources.

In the event of a fire, the safety of the resident is the top priority. By attempting to get the resident out of the room and closing the door, the nurse aid can help contain the fire and prevent it from spreading to other areas. This action also ensures the resident's immediate safety by removing them from the dangerous environment. The other options, such as using a fire extinguisher or taking away the resident's cigarettes, may not be as effective or prioritize the resident's safety in the same way. Pulling the fire alarm is also important, but it should be done after ensuring the resident's safety.

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 infectious disease. Prompt reporting is necessary to ensure that appropriate measures are taken to prevent the spread of any potential infection and to provide timely treatment to the patient.

A client with a broken hip requires a fracture pan for an enema. This is because a fracture pan is specifically designed with a low rim and a flat surface, making it easier for the client to position themselves without causing discomfort or further injury. Plastic, pediatric, and metal pans may not provide the same level of support and comfort needed for a client with a broken hip.

The ABC's of emergency care stand for airway, breathing, circulation. This acronym is used to prioritize the steps in providing immediate medical assistance in emergency situations. The first step is to ensure that the person's airway is clear and open, followed by checking their breathing and then assessing their circulation. This sequence is crucial in order to address life-threatening conditions and provide the necessary support to the individual in need.

It is important to practice standard precautions when providing oral hygiene because this involves direct contact with the patient's mouth and potential exposure to saliva, blood, and other bodily fluids. Standard precautions include wearing gloves, masks, and protective eyewear, as well as proper hand hygiene before and after the procedure. These precautions help to prevent the transmission of infectious agents and maintain a safe and hygienic environment for both the patient and the healthcare provider.

The correct answer is b. voiding because voiding refers specifically to the act of emptying the bladder by releasing urine. The term "unrination" is not commonly used or recognized, but "voiding" is a widely accepted term in medical and anatomical contexts to describe the process of urination. The other options, such as defecation (which refers to the elimination of feces), wetting the bed (which refers to involuntary urination during sleep), and flatus (which refers to the release of gas from the digestive system) are not synonymous with urination.

Visually challenged clients use a "clock" system to find their food. This means that they mentally divide their plate into sections, with each section representing a specific food item. By using this system, they can locate and identify different food items on their plate based on their position, similar to the positions on a clock. This method helps visually challenged individuals navigate their meals independently and efficiently.

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

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. Peri-care is a necessary and common practice in healthcare, and using gloves is a standard precaution to prevent the spread of infection. The other options, 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 involve intentionally causing discomfort or neglecting the client's needs.

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 awareness, there is a possibility that they can still hear and process auditory information. This can provide comfort and reassurance to the client, as well as help maintain a sense of dignity and respect in the care being provided.

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's first action should be to grasp the transfer belt and lower the client to the floor. This is done to prevent the client from falling and potentially getting injured. Holding the transfer belt provides stability and control, allowing the nurse's aide to safely lower the client to the floor. Calling for help and holding the client tightly may be necessary actions, but the immediate priority should be to prevent the client from falling.

Sputum is best collected upon awakening in the morning because during the night, secretions in the respiratory tract accumulate and become more concentrated. This makes it easier to cough up sputum in the morning, providing a better sample for analysis. Collecting sputum at this time also allows for a more accurate diagnosis of respiratory conditions, such as infections or diseases.

The correct answer is d left Sim's. In a left Sim's position, the patient lies on their left side with the left leg straight and the right leg flexed. This position allows for easier insertion of the enema tube into the rectum and promotes the flow of the enema solution. It also helps to prevent leakage and discomfort for the patient during the procedure.

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 the recommended first aid technique for choking victims who are conscious and unable to speak. This technique involves applying upward pressure to the abdomen to forcefully expel the object blocking the airway. It is important to call for help first in order to ensure that additional assistance is available if needed.

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 for proper cleaning. The laundry bag can be easily transported to the laundry room or designated area for cleaning, preventing any potential contamination or spread of germs. Placing the soiled linen on the bedside table or on the floor would not be hygienic or appropriate. Using a red plastic bag may not be necessary unless there are specific protocols in place for infectious or hazardous materials.

The vital signs that should be reported immediately are the ones 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 rate (P) is low at 40, the respiratory rate (R) is low at 10, and the blood pressure (BP) is low at 80/40. These abnormal vital signs could indicate hypothermia, bradycardia, bradypnea, and hypotension, which are all serious conditions that require immediate attention.

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 harm that may occur during smoking. By staying with the patient, the nurse aide can monitor the situation and respond promptly if any issues arise. This approach allows for appropriate supervision and support while respecting the patient's autonomy and choices within the facility's smoking policy.

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 romantic relationships, and having muscular dystrophy does not change this basic human need for connection and love.

When providing postmortem care, it is important for the nurse aide to wear gloves. This is because postmortem care involves handling the deceased person's body, which may have bodily fluids or other substances that could potentially be infectious. Wearing gloves helps to protect the nurse aide from coming into direct contact with these substances and reduces the risk of infection or cross-contamination.

The nurse aide should carry the bag below bladder level to prevent urine from flowing back into the bladder and causing infection. This position helps maintain proper drainage and prevents any tension or pulling on the catheter.

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 properly aligned and not twisted or bent in any way. This is important for maintaining proper posture and preventing any strain or discomfort for the client. It also helps to promote proper circulation and prevent pressure ulcers. By keeping the client straight as possible, the nurse aide is promoting overall comfort and well-being for the client.

The client's inability to speak and clutching her neck suggests that she may be choking. Performing the Heimlich maneuver is the appropriate response in this situation as it is a technique used to help clear a person's airway when they are choking. It involves applying pressure to the abdomen to create an upward force that can help dislodge the obstruction. This action should be taken first to try and alleviate the choking before seeking additional help or offering a drink of water.

The client's lack of bowel movement for five days indicates possible constipation or bowel obstruction, which can lead to nausea. Nausea is a common symptom associated with bowel issues, as the body's digestive system becomes disrupted. The other symptoms listed (headache, leg cramps, chest pain) may or may not be related to the client's bowel movement issue and would require further investigation to determine their cause.

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 facilitate effective communication with the hearing impaired client.

When a nurse aide accidentally gets blood in her eyes, the first action she should take is to rinse them out with clear water. This is important because rinsing the eyes with water can help to flush out any potential contaminants and reduce the risk of infection or other complications. Calling 911 may not be necessary in this situation unless there are severe symptoms or complications. Reporting the incident to the charge nurse and documenting it should also be done, but these actions can be taken after rinsing the eyes.

During a seizure, it is important to protect the client from injuring themselves. Holding the client down may cause further harm or injury. Putting a tongue depressor in the client's mouth is not recommended as it can cause damage to the teeth, gums, or airway. Running out of the room to get help may leave the client unattended and at risk of injury. Therefore, the nurse aide should focus on ensuring the client's safety by protecting them from any potential harm during the seizure.

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 at the apex of the heart, which is located at the fifth intercostal space at the midclavicular line. The stethoscope helps amplify the sound of the heartbeat and allows the nurse aide to accurately count the number of beats per minute. This method is commonly used in healthcare settings to assess the heart rate and rhythm of patients.

When forcing fluids, the nurse aide should offer fluids every hour. This is important because it ensures a consistent intake of fluids throughout the day, which helps to prevent dehydration. Offering fluids every hour also allows for frequent monitoring of the patient's fluid intake and helps to ensure that they are receiving an adequate amount of fluids.

Reality orientation techniques are used to help individuals with cognitive impairments stay connected to reality and improve their orientation to time, place, and person. These techniques involve strategies such as labeling items in the client's room, putting up calendars and clocks, and using familiar items in the client's room. However, reminding a client that his spouse is deceased would not be considered a reality orientation technique. This statement does not align with the goal of reality orientation, which is to provide support and enhance the individual's sense of reality and well-being.

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 restlessness or agitation. By continuing to observe the client, the nurse aide can monitor their behavior and ensure their safety. Restraining the resident (option a) may not be necessary or appropriate, walking with the resident (option b) may not be feasible or necessary at all times, and placing the resident in a locked room (option c) may be considered a form of seclusion and is generally not recommended unless there is a safety concern.

The correct answer is a proper body mechanics. When transferring a client from a bed to a stretcher, it is important for the nurse aide to use proper body mechanics to ensure the safety of both the client and themselves. Proper body mechanics involve using the correct posture, body alignment, and movement techniques to prevent injury and strain on the muscles and joints. This includes bending the knees, keeping the back straight, and using the leg muscles to lift and move the client. By using proper body mechanics, the nurse aide can effectively transfer the client without causing harm.

Being sneezed on can lead to possible contamination through direct contact because respiratory droplets containing bacteria or viruses can be transmitted from the person who sneezed to the person who is being sneezed on. This direct contact with the respiratory droplets can result in the transfer of pathogens and potential infection.

A bedpan is the most appropriate option for a weak and unsteady client who needs to urinate because it can be used while the client is lying down or sitting on the edge of the bed. This ensures that the client does not have to bear weight or risk falling while trying to use a commode or toilet. A bedpan also provides support and stability for the client, making it the safest option. A urinal is not suitable for a client who needs to urinate because it is designed for male clients and requires the client to be in an upright position.

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 back. By turning the whole body and using the feet to pivot, the nurse aide can ensure a safe and efficient change of direction without putting unnecessary strain on the back or other body parts.

The nurse aide should position the wheelchair at the side of the bed, facing the foot of the bed. This allows the client to easily transfer from the bed to the wheelchair by sliding onto the seat. Placing the wheelchair at the side of the bed also ensures that the client's feet are facing towards the foot of the bed, which helps in maintaining proper body alignment during the transfer.