Question 1

Angie is a disoriented client who frequently falls from the bed. Which of the following is the best intervention to prevent future falls?

Accepted Answer

Put the bed in the lowest position possible. The risk of falling increases with age. Most falls occur in the evening, between 6:00 PM and 9:00 PM. The care plan for preventing falls from bed includes:
Placing the bed in the lowest horizontal position, except when giving bedside care. The distance from the bed to the floor is reduced if the client falls or gets out of bed.
A special mattress or mat is on the floor next to the bed if ordered. This reduces the chance of injury if the person falls.
If the person uses bed rails, check the person often.
Furniture is placed for easy movement.
A telephone and lamp are placed within the person's reach.

Question 2

Which of the following measure(s) is /are included in the care plan of clients with fecal incontinence?
I. Help with elimination after meals and every 2 to 3 hours
II. Provide good skin care after every elimination
III. Assist the nurse in the insertion of a suppository as ordered by the physician
IV. Apply of incontinence products
V. Eliminate foods that are gas-forming (cabbage, cauliflower, radish, beans, onions, and cucumbers)

Accepted Answer

Fecal incontinence is the inability to control the passage of feces and gas through the anus. The client may need bowel training, help with elimination after meals and every 2 to 3 hours, incontinence products to keep garments and linens clean, good skin care, and avoidance of gas-forming foods.

Question 3

Ms. Walsh scratches and picks at a wound in her right foot. Because she is diabetic, the nurse obtained a doctor's order to apply mitt restraints. You were delegated by the nurse to monitor Ms. Walsh after the restraints were applied. Which of the following are important to report to the nurse?

Accepted Answer

Make sure the restraint is snug, not tight. Slide one or two fingers between the restraint and the wrist. Adjust the straps if the restraint is too loose or too tight. Check the client and the restraint every fifteen minutes; check for pulse, color, and temperature of the restrained part.

Question 4

The nurse aide identifies a reddened area that does not blanch over the client's sacrum. The nurse aide should

Accepted Answer

The nurse aide should reposition an immobile client every two hours while in bed and every hour in a chair in order to prevent pressure ulcers. Massaging the area will help increase blood flow, but the priority treatment to prevent further breakdown is repositioning. Performing range-of-motion exercises with the client will help to prevent complications of immobility, but frequent repositioning, pressure relief devices, and skin care can help prevent pressure ulcers. If a pressure ulcer forms, a dressing can be used to expedite healing by removing unwanted debris from the ulcer surface, protecting exposed viable tissues, and or providing a barrier between an open ulcer and the environment. Applying sterile dressings is more of a responsibility of the licensed nurse.

Question 5

The physician has ordered to bladder training for a client with an indwelling catheter. The goal of bladder training is to

Accepted Answer

Bladder training programs help some persons with urinary incontinence. Control of urination is the goal. Bladder control promotes comfort and quality of life. You assist with bladder training as directed by the nurse and the care plan.

Question 6

Jeremy (CNA) is assisting Mr. Shank walk in the hallway. After several steps, the client complained of light-headedness and suddenly fainted. What should be Jeremy's initial action?

Accepted Answer

If a client starts to fall, bring him/her close to your body as fast as possible or wrap your arms around the client's waist. If necessary, you can also hold the client under the arms. Then lower him/her to the floor. The client slides down your leg to the floor. Bend at your hips and knees as you lower the client. Call a nurse to check the client. Stay with the client. Help the nurse return the client to bed. Get other staff to help if needed.

Question 7

When removing gowns and gloves, which of the following is inappropriate?

Accepted Answer

When removing gloves, it is inappropriate to remove your mask and gown before removing your gloves. The correct order in removing protective wear is: gloves, mask, gown, eyewear or goggles, cap, shoe cover. Washing your gloved hands reduces the number of microorganisms that could contaminate the hands. When you remove your gloves, first use your gloved, dominant hand to remove other glove by grasping it just below wrist. Pull this glove down over your non-dominant hand so that it is inside out. Hold the removed glove in your gloved hand. With the first two fingers of your ungloved hand, reach inside the glove without touching the outside of the glove. Pull the glove down (inside out) over your hand and remaining glove. Discard the gloves in a waste receptacle. Remember the technique of glove-to-glove and skin-to-skin contact in removing gloves.

Question 8

Which of the following is the most effective practice by caregivers and family when caring for a client with low resistance to infection due to cancer?

Accepted Answer

Hand washing is the most effective practice to prevent transfer of microorganisms. The other choices do not apply to the situation.

Question 9

Macy, the new nurse aide, is about to take a client's rectal temperature as ordered by the nurse. Which of the following actions show that Macy is doing the procedure inappropriately?

Accepted Answer

Explaining the procedure to the client before doing it decreases or eliminates anxiety; however, the client should be placed in the left-side lying position, not the ride-side lying position. This position facilitates easy insertion of the probe into the anus as it follows the normal anatomical position of the colon. The other choices are correct actions for the nursing assistant in obtaining rectal temperature.

Question 10

Mrs. Moore, a 69-year-old client, is emaciated. The nurse aide takes precautionary measures in order to prevent which of the following problems in skin integrity?

Accepted Answer

Pressure sores are a concern with emaciated clients. Factors that contribute to the formation of pressure ulcers include the following: immobility, prolonged inadequate nutrition that causes weight loss, muscle atrophy, and loss of subcutaneous tissue; fecal and urinary incontinence; decreased mental status; diminished sensation; excessive body heat; and advanced age.

Question 11

All of the following are correct methods in obtaining blood pressure except:

Accepted Answer

Do not pump the cuff to 50 mmHg above the point where the pulse is obliterated. The cuff should be inflated within 30 mmHg above estimated systolic pressure (around 8 seconds). If measuring the blood pressure for the first time, measure the blood pressure in both arms and record the second set of measurements as the baseline. For subsequent measurements, use the arm with the highest initial reading. The audible sounds heard over the stethoscope while deflating the cuff are called Korotkoff's sounds. The nursing assistant needs to be familiar with the different phase of Korotkoff's sounds. In taking the blood pressure, the nursing assistant needs to observe infection control as well.

Question 12

A client is admitted to the unit with an order for hourly monitoring of blood pressure. The nurse aide finds that the cuff is too small. This will cause the blood pressure reading to be:

Accepted Answer

Using a cuff that is too small will cause the blood pressure reading to be higher than what it should be. In obtaining the blood pressure it is important to select the proper size blood pressure cuff (sphygmomanometer). The cuff should fit 40% of the upper arm (if cuff is too small, the reading will be falsely high; if too large, the reading will be a false low reading).

Question 13

In order to get an accurate reading, how long should you wait after a client smokes or drinks coffee before taking his or her blood pressure?

Accepted Answer

You should wait 30 minutes to take the client's blood pressure. Cigarette smoking and coffee cause vasoconstriction. Vasoconstriction leads to increased BP. Allowing the client to rest for 30 minutes will facilitate the return of normal blood circulation and can provide accurate BP reading.

Question 14

When performing oral care on an unconscious client, which of the following prevents aspiration of fluids into the lungs?

Accepted Answer

Put the client on a side-lying position with the head of the bed lowered. When giving oral care to a comatose client (one who is unconscious), turn the client's head to the side and gently swab his or her mouth and mucous membranes with the recommended equipment and supplies while being careful not to cause the client to aspirate, which means accidentally drawing food or fluid into the air passage.

Question 15

The doctor orders for a "daily urine specimen to be sent to the laboratory" for Eileen, who was operated on for renal stones. Eileen has a Foley catheter attached to a urinary drainage system. How will you collect the urine specimen?

Accepted Answer

Remove urine from the drainage tube with a sterile needle and syringe and empty urine from the syringe into the specimen container.

Question 16

Just as the nurse aide was entering the room, the client who was sitting on his chair begins to have a seizure. Which of the following must the nurse aide do first?

Accepted Answer

The nurse aide should first ease the client to the floor. Seizures or convulsions are violent and sudden contractions or tremors of muscle groups. You cannot stop a seizure. However, you can protect the client from injury. Guidelines to follow during a seizure activity are:
§Do not leave the person alone.
§Lower the person on the floor. This protects the person from falling.
§Place a folded blanket, towel, cushion, pillow, or other soft item under the person's head or cradle the person's head in your lap.
§Turn the person onto his or her side. Make sure the head is turned to the side.
§Loosen tight jewelry and clothing (ties, scarves, collars, necklaces) around the neck.
§Move furniture, equipment, and sharp objects away from the person.
§Do not give the person food and fluids.
§Do not try to restrain body movements during the seizure.
§Do not put any object or your fingers between the person's teeth.

Question 17

Mr. Santos is placed on seizure precaution. Which of the following would be contraindicated?

Accepted Answer

Obtaining his oral temperature would be contraindicated. Seizures occur suddenly; sometimes the person is not aware that a seizure just happened. Obtaining the temperature orally can pose an injury as the person bites into the thermometer while the seizure is going on.

Question 18

The nurse aide is demonstrating proper foot care to a diabetic client. Which of the following is an appropriate action?

Accepted Answer

The nurse assistant should apply a moisturizing lotion to dry feet, but not between the toes. The moisture between the toes can encourage fungus growth. Other guidelines for foot care are the following:
§Wash feet every day. Dry them carefully, especially between the toes.
§If the person can see and reach the toenails, trim them when needed. Trim toenails straight across, and file the edges with an emery board or nail file.
§Wear shoes and socks at all times. Never walk barefoot. Wear comfortable shoes that fit well and protect the feet. Check the insides of the shoes before wearing them. Make sure the lining is smooth and there are no objects inside.
§Protect feet from hot and cold. Wear shoes at the beach or on hot pavement. Don't put feet into hot water. Test water before putting the feet in it. Never use hot water bottles, heating pads, or electric blankets. The person can burn his feet without feeling it.
§Keep the blood flowing to the feet. Put feet up when sitting. Wiggle toes and move ankles up and down for 5 minutes, two (2) or three (3) times a day. Don't cross legs for long periods of time. Don't smoke.

Question 19

When you say sterile, it means:

Accepted Answer

Sterilization is the process of killing all microorganisms, including spores and viruses. Cleaning a material, rather than sterilizing it, only limits the number of pathogens present and reduces the ability of the pathogen to cause infection. The presence of a black stripe on the paper indicator is not a reliable indicator that the material is sterile, even though the autoclave tape turns black after fifteen minutes of sterilization.

Question 20

Apnea seen in clients with Cheyne-Stokes respiration is defined as:

Accepted Answer

Apnea in clients with Cheyne-Stokes respiration is defined as an absence of breathing for a period of time, usually 15 seconds or more. Choice A refers to orthopnea. Technically, apnea is lack or absence of breathing, but choice B is not the correct answer. The question is asking for the description of apnea in a Cheyne-Stokes respiration, not referring to a dead person. Choice D refers to hypoventilation.

Quiz 1: Physical Care