Which of the following pulse will be most commonly used by a nursing assistant when acquiring vital signs?

The nursing assistant knows that the responsibilities of his/her position do not include:A. Helping a resident to bathe.B. Applying an icepack as ordered.C. Keeping a resident’s room tidy.D. Administering a medication.

Administering a medication.Nursing assistants may not administer medications, it is not within their scope of practice. Only RNs, LPNs, and other properly licensed personnel may give medications.

Which of the following would be considered an example of battery toward a patient?A. The nursing assistant asks for permission before touching the resident to assist them to the bathroom.B. The nursing assistant bathes the resident without his or her permission.C. The nursing assistant cleans the resident’s glasses.

D. The nursing assistant keeps a resident isolated from others as a form of punishment.

The nursing assistant bathes the resident without his or her permission.

Bathing a resident without his or her permission is an example of battery. Keeping a resident isolated from others as a form of punishment is an example of involuntary seclusion.

The nursing assistant suspects that a resident in the facility is being abused due to multiple unexplained bruises, refusal to answer most questions, and refusal of ADLs. Which of the following actions should the nursing assistant take next?A. Wait for more proof in order to identify the abuser.B. Ask the resident repeatedly to identify an abuser.C. Report the suspected situation to the nursing assistant’s immediate supervisor.

D. Notify the nurse assigned to care for the patient about the bruises.

Report the suspected situation to the nursing assistant’s immediate supervisor.

Abuse in nursing facilities, or even suspicion of abuse, should be reported immediately to the nursing assistant’s supervisor. This requires more intervention than the nursing assistant’s scope of practice covers. Waiting or notifying the nurse only about bruises may delay getting the resident help.

MRSA is an example of which of the following?A. A resistant strain of bacteria that is difficult to treat with antibiotics.B. A set of activity guidelines designed to keep residents safe.C. A mnemonic to remember how to act if there is a fire in the facility.

D. A bacterial strain that is easy to treat with antibiotics.

A resistant strain of bacteria that is difficult to treat with antibiotics.

MRSA stands for methacillinn-resistant Staphylococcus aureus and is very resistant to most antibiotic treatments.

What is the best way for a nursing assistant to prevent infection?A. Apply an antiseptic hand rub before and after caring for residents.B. Use standard precautions when caring for residents.C. Frequent hand washing.

D. Wear gloves when in contact with body fluids.

Frequent hand washing.

Frequent hand washing is the best way to prevent infection without a doubt. The other measures are supportive.

Which of the following is a key part of care when administering a bath to a resident?A. Perform all care for the resident in order to conserve their energy.B. Clean the perineal area of a patient before assisting them to clean their face.C. Use cool water when bathing the patient to promote better circulation.

D. Allow participation in care to promote a sense of independence.

Allow participation in care to promote a sense of independence.

Allowing the resident to participate in care will raise their self esteem and allow autonomy. It is inappropriate to clean the perineal area before the face, or to use cool water rather than comfortably warm water.

A nursing assistant cares for a resident. Which of the following skin care measures are correct?A. The nursing assistant does not begin perineal care until a second staff member is present.B. The nursing assistant applies a prescription ointment as ordered.C. The nursing assistant applies talcum powder beneath the abdominal folds of the resident.

D. The nursing assistant notes an unblanchable red area on the resident’s sacrum and reports it to the nurse.

The nursing assistant notes an unblanchable red area on the resident’s sacrum and reports it to the nurse.

It is the duty of the nursing assistant to report any red pressure spots on the resident to the nurse. The nursing assistant may not apply any prescription ointments. Talcum powder is not recommended. A second staff member is not needed for perineal care.

Before shaving a resident, the nursing assistant checks for which of the following items in the resident’s care plan?A. History of a heart condition.B. Shaving instructions related to problems or issues clotting.C. Presence of the resident’s razor from home.

D. Any previous refusal of ADLs.

Shaving instructions related to problems or issues clotting.

It is necessary to check the shaving instructions in the resident’s plan of care to be aware of any problems clotting and the necessity of using an electric razor as opposed to a traditional one.

Fecal impaction may present with which of the following symptoms?A. Dark urine.B. Abdominal pain.C. Excessive flatulence.

D. Small, watery leakage of stool.

Small, watery leakage of stool.

The watery leakage of stool around a blockage is the most specific sign of fecal impaction, also known as a bowel obstruction.

Dyspnea is a term that refers to difficulty with which of the following?A. Defecating.B. Swallowing.C. Urinating.

D. Breathing.

Breathing.

Dyspnea is a term that refers to difficulty with breathing.

Which of the following statements is true about Alzheimer’s residents?A. The resident may become confused, but hallucinations are never a part of Alzheimer’s.B. It is important to maintain a routine to avoid confusion and overstimulation.C. An increased appetite is common as Alzheimer’s progresses.

D. Residents can never be reoriented because they will immediately forget it

It is important to maintain a routine to avoid confusion and overstimulation.

Maintaining a routine is incredibly important to Alzheimer’s patients. Hallucinations and a decrease in appetite are common. It is important to frequently reorient the patient.

Which of the following is a correct aspect of making an occupied bed?A. Place soiled linen on the floor until the bed has been remade with clean sheets.B. Mitering the corners of the new sheet is no longer recommended.C. Lower the bed to the lowest level when the procedure is complete.D. Avoid raising the bed rails unless absolutely necessary.

Lower the bed to the lowest level when the procedure is complete.

Lowering the bed to the lowest level is important for safety. Mitering the corners of sheets is recommended, as is raising side rails. Never place soiled linens on the floor.

Which of the following is an example of a pulse rate that should be reported to the nurse?A. 45.B. 82.C. 64.D. 98.

45.

Any pulse outside the range of 60 to 100 should be reported immediately to the nurse for the resident’s safety.

The nursing assistant knows that signs of hypoglycemia include which of the following?A. Tachycardia.B. Hot and dry skin.C. Polyuria.D. Sweating.

Sweating.

Sweating, as well as confusion and tremors, are signs of hypoglycemia.

Which of the following guidelines regarding residents who are hard of hearing would be considered correct?A. Encourage family participation to make sure they understand you.B. Speak clearly and slowly as you face the resident.C. Write down words rather than speaking.D. Speak in a high-pitched voice to enhance understanding.

Speak clearly and slowly as you face the resident.

Speaking slowly and clearly is the key to helping hard-of-hearing clients understand what you’re saying.

A resident is ordered to be in High Fowler position for each meal. Which of the following descriptions is the most accurate depiction of High Fowler position?A. The patient lies on their stomach for twenty minutes prior to eating.B. The patient’s bed is at a 60 degree angle with the feet propped up.C. The patient’s bed is at a 30 degree angle with the patient slightly slumped over to the left.D. The patient's bed is at a 90 degree angle and the patient is positioned sitting up.

The patient's bed is at a 90 degree angle and the patient is positioned sitting up.

High Fowlers is a description of the patient sitting straight up in bed, meaning the bed itself has to be at a 90 degree angle to support them.

What protective equipment should be worn when changing an incontinent patient?A. Gloves, gown, and a mask.B. Mask and gown.C. N-95 mask.D. Gloves and gown.

Gloves and gown.

The nursing assistant should wear a gown and gloves at most as correct contact precautions.

Of the following symptoms, which one is most likely due to an infection in a resident?A. Pale skin.B. Sudden onset confusion.C. Tented skin.D. Aphasia.

Sudden onset confusion.

Infection, especially in older clients, tends to cause sudden onset confusion. Tented skin may be normal for an older client, as could pale skin. Aphasia could indicate the onset of a stoke.

The nursing assistant knows that the term “NPO” means:A. Bedrest only.B. No oral temperatures are to be taken.C. Liquid diet.D. Nothing by mouth.

Nothing by mouth.

NPO is a latin abbreviation that stands for “nil per os” or “nothing by mouth.” It indicates that the client is not allowed food, fluids, or oral medications.

The nursing assistant should tell the nurse if the client with diabetesA. does not touch their lunch tray.B. decides not to finalize a will.C. reports numbness in their feet sometimes.D. combs their hair without being prompted.

does not touch their lunch tray.

Someone with diabetes should always eat regular meals to keep their blood sugar relatively stable. Numbness in the feet is neuropathy, a common side effect of diabetes.

The nursing assistant knows that residents on bedrest must be turned everyA. 6 hours.B. 8 hours.C. 1 hour.D. 2 hours.

2 hours.

Residents on bedrest must be turned every 2 hours to maintain skin integrity.

Which of the following pulses will be most commonly used by a nursing assistant when acquiring vital signs?A. Popliteal.B. Radial.C. Brachial.D. Femoral.

Radial.

The radial pulse is the most easily accessible location to take a pulse.

The nursing assistant is helping residents to eat in the dining room when, suddenly, a resident stands from their seat and begins clutching their throat while coughing silently. The nursing assistant performs which of the following actions first?A. Ask the resident if they are choking.B. Begin CPR immediately.C. Call 911.D. Begin the Heimlich maneuver.

Ask the resident if they are choking.

It is important to first assess whether or not the resident is choking. If they are able to answer, air is still moving through the trachea. If they nod yes, but are unable to speak, it is time to begin the Heimlich maneuver. The Heimlich should not be performed on anyone who is able to cough or speak.

A client at the facility receives a new roommate. While the roommate is in the bathroom, the clients leans toward the nurse and whispers, “Why is she here anyway? Is she sick?” The best response by the nursing assistant isA. “Why don’t you ask her yourself?”B. “I’m afraid I can’t share that information with you.”C. “She’s here for the same thing as you!”D. “I’m not sure. Let me take a look at her chart.”

“I’m afraid I can’t share that information with you.”

HIPPA requires you to keep client’s health information confidential. Period.

A client with Alzheimers wakes up more confused than usual one morning. The nursing assistant knows that, after breakfast, it is most important to support normal gastrointestinal tract function byA. recording intake and output.B. taking the client to the bathroom.C. assisting the client to call family members.D. brushing the client’s teeth.

taking the client to the bathroom.

Taking the client to the bathroom will most likely prompt a bowel movement, which supports GI tract health. A confused patient may not remember what the urge means.

The client asks the nursing assistant to assist her to cut her toenails. The nursing assistant knows this client has type two diabetes. Which of the following actions is best?A. Check the client’s blood glucose before cutting her toe nails.B. Check the chart for physician orders regarding nail trimming.C. Report to the nurse that the client needs her toenails trimmed.D. Retrieve a safety clipper and hand it to the client.

Check the chart for physician orders regarding nail trimming.

Diabetic clients often have special instructions regarding nail trimming. Check the chart for specific orders.

Which of the following options is the best method to prevent insomnia?A. Ensure the client eats one apple per day.B. Encourage the client to take several walks around the facility daily.C. Encourage the client to take several naps daily.D. Encourage the client to remain in bed throughout the day.

Encourage the client to take several walks around the facility daily.

Walking and physical activity during the day promotes rest and well-being at night.

The nursing assistant takes the temperature of an elderly client and finds it to be 100.6 degrees F. The client reports having just taken a sip of hot tea. Which of the following actions is appropriate?A. The nursing assistant records the temperature in the chart.B. The nursing assistant scolds the client for not letting her know beforehand.C. The nursing assistants waits at least fifteen minutes before retaking the temperature.

D. The nursing assistant takes an axillary temperature instead.

The nursing assistants waits at least fifteen minutes before retaking the temperature.

Waiting fifteen minutes ensures the temperature of the mouth will be more accurate. Axillary temperatures in the elderly are often not the best measure.

A client under the nursing assistant’s care suffers from chronic “foot drop”. The nursing assistant can expect to find which of the following devices in the client’s room?A. A mechanical lift.B. Two extra pillows.C. Positioning boots.D. A wedge.

Positioning boots.

The boots will ensure that the feet are dorsiflexed to prevent contractures and discomfort.

A nursing assistant takes the blood pressure of a client and finds it to be 82/43. The client reports feeling dizzy. The nursing assistant shouldA. take the client’s pulse next.B. instruct the client to drink more fluids.C. record the vital sign in the chart.D. report the finding to the nurse.

report the finding to the nurse.

It is very important to report a symptomatic low blood pressure to the nurse for further investigation.

The range of motion term “abduction” meansA. moving the extremity above the body.B. moving the extremity below the body.C. moving the extremity away from the body.D. moving the extremity toward the body.

moving the extremity away from the body.

To abduct is to move away, to adduct is to move closer or toward.

Which of the following most addresses a client’s needs in regard to spirituality?A. Treat any religious objects in the client’s room as if they were any other.B. Ask the client why he or she is of a particular faith.C. Assist the client to the facility’s chapel every Sunday.D. Provide the client with warm water, soap, and towels every morning.

Assist the client to the facility’s chapel every Sunday.

Support the client in their own individual religious needs. Treat any religious objects in their room with respect.

Proper body mechanics when lifting clients involve which of the following?A. Avoid seeking assistance.B. Keep the spine curved.C. Bending at the knees.D. Bending at the waist.

Bending at the knees.

Bending at the knees is the only proper body mechanic listed. Avoid doing all the others!

Which of the following would be a primary indication of hepatitis?A. Jaundice.B. Hypotension.C. Hyperglycemia.D. Hypertension.

Jaundice.

Jaundice, also known as yellowing of the skin, occurs frequently in cases of hepatitis (liver disease).

Which of the following aspects of care is important for a confused client?A. Asking the client their name.B. Reorienting the client frequently with clocks, calendars, and family mementos.C. Keeping the client contained in their room.D. Checking the client’s blood sugar every hour.

Reorienting the client frequently with clocks, calendars, and family mementos.

Reorienting the patient frequently is the most important aspect of care. Keeping the client locked in their room could agitate them, as could asking them their name (which they might not remember).

What type of client may opt to receive hospice care?A. Client with cancer.B. Terminally ill client.C. Client with kidney disease.D. Client with diabetes.

Terminally ill client.

Terminally ill clients may receive hospice care, which is designed to relieve pain rather than to cure disease.

Cheyne-Stokes respirations occur in a client whoA. has a history of chronic respiratory issues.B. is recovering from an asthma attack.C. is unconscious.D. is close to death.

is close to death.

Cheyne-Stokes respirations are a breathing pattern marked by increased respirations, labored breathing, and periods of apnea (no breathing). It is important to report these signs if discovered in a resident who is not expected to show them.

A client in the day room is having a panic attack. The nursing assistant should:A. ask the client about the cause of the panic attack.B. tell the client to breathe as slowly and deeply as possible.C. encourage the client to verbalize their feelings.D. have the client talk about the panic attack.

tell the client to breathe as slowly and deeply as possible.

During a panic attack, the nursing assistant should make the client comfortable and encourage them to breathe slowly and deeply. Asking them to count backwards slowly from 100 can also be helpful. During an attack, the client is unable to talk about anxious situations and isn’t able to address uncomfortable feelings and frustrations. While having a panic attack, the client is also unable to focus on anything other than the symptoms, so the client won’t be able to discuss the cause of the attack.

Which of the following residents is demonstrating orthopneic position?A. A resident lays on their stomach with their face to the side.B. A resident walks using a cane.C. A resident sits in a chair with their back straight.D. A resident sits on the side of the bed and leans forward over a bedside table.

A resident sits on the side of the bed and leans forward over a bedside table.

Orthopneic position is meant to assist in breathing. Leaning forward makes it easier to get air into the lungs.

A resident is choosing items for breakfast. Which of the following items contains the most amount of potassium?A. Cantaloupe.B. Eggs.C. Strawberries.D. Toast.

Cantaloupe.

Cantaloupe is a melon that contains massive amounts of potassium. Other foods that contain high potassium include bananas and dark leafy greens.

When helping a client with left-sided weakness due to a CVA, the nursing assistant should position the client’s caneA. away from the client.B. on the left side.C. on the right side.D. in front of the client.

on the right side.

The nursing assistant should place the cane on the side that is the strongest so that it can support the weak side.

CPR (Cardiopulmonary resuscitation) should be performed whenA. a client has a pulse but is not breathing.B. a client has no pulse and is not breathing.C. a client is choking.D. a client is unconscious.

a client has no pulse and is not breathing.

CPR is performed on a client that has no pulse and is not breathing.

A nursing assistant enters a client’s room and finds a fire burning in a trashcan. The nursing assistant’s first action is toA. pull the fire alarm.B. remove the patient.C. try to put out the fire.D. call the nurse for help.

remove the patient.

The acronym “RACE” is used for fire situations- Rescue, alarm, contain, extinguish. First you must rescue the client to prevent harm.

“Log-rolling” is a technique best used for which of the following patient diagnoses?A. Left tibial fracture.B. Spinal cord injury (SCI).C. Psychosis.D. Cellulitis of the right arm.

Spinal cord injury (SCI).

A SCI patient is prone to further damage and injury to the spinal cord if the legs cross over the midline (in a twisting motion). This can be avoided with proper log-rolling technique.

When a client constantly ignores the urge to void, the client is putting themselves in danger of what complication?A. Insomnia.B. Poor appetite.C. Constipation.D. Incontinence.

Incontinence.

Incontinence can occur if the bladder becomes too full and is unrelieved.

Which of the following types of grief is considered a normal and healthy part of grieving?A. Anticipatory.B. Complicated.C. Inhibited.D. Unresolved.

Anticipatory.

Anticipatory grief occurs before the loss actually happens and is a normal part of grieving. Complicated, unresolved, and inhibited grieving indicate there is a problem with recovering from the loss.

A patient is on a clear liquid diet. Which of the following is NOT allowed on this diet?A. Water.B. Orange juice with pulp.C. Tea.D. Coffee.

Orange juice with pulp.

Orange juice with pulp is not allowed- the pulp is not considered part of “clear liquid.” Tea, coffee, and water are all allowed on the clear liquid diet.

A client with a Foley catheter is ordered to ambulate twice daily. Before ambulating the client, the nursing assistant shouldA. keep the bag below the bladder level.B. ask the nurse to confirm this order.C. have the patient cover the bag with a pillow sleeve.D. raise the bag above the bladder level.

keep the bag below the bladder level.

Keeping the bag below the level of the cavity ensures that bacteria cannot migrate up from the bag and up into the bladder due to gravity.

Which of the following items is necessary in order to place a patient in restraints?A. The hospital administrator’s approval.B. The charge nurse’s approval.C. Physical restraints.D. A physician’s order.

A physician’s order.

The physician needs to order restraints before they can be legally applied. No one else can ask for restraints for a patient or it is considered battery.

A client eats a bagel and one large glass of orange juice. What is the correct way to record the amount of juice?A. 120 ml.B. 480 cc.C. 480 ml.D. One hundred and twenty cc.

480 ml.

The abbreviation of “cc” is no longer appropriate in the medical field. Only ‘ml’ should be used. A large glass is 480 ml.

One of the patients on the unit is on airborne precautions due to suspected tuberculosis. To rule out the disease, the doctor has ordered sputum specimens to be collected. What is the best daily time for the nursing assistant to collect the specimens?A. Last thing before the patient goes to sleep.B. After a meal.C. First thing in the morning.D. Before a meal.

First thing in the morning.

The sputum produced upon awakening is the most concentrated sputum and will yield the most accurate result.

The nursing assistant walks into a patient’s room and discovers him masturbating. Which of the following actions is correct?A. Scold the patient and tell him he should be ashamed of himself.B. Exit the room to provide privacy for the patient.C. Report the activity to the nurse in charge.D. Ask the patient why he is doing this to himself.

Exit the room to provide privacy for the patient.

Masturbation is a normal expression of sexual health. Attempt to exit quietly without disturbing the client in order to preserve his privacy and decency.

The nursing assistant cares for a client who is extremely agitated. She yells, screams, and frequently tries to bite staff. The nursing assistant shouldA. speak calmly in an authoritative and neutral manner to the client.B. provide care only when absolutely necessary.C. use the television to distract the client.D. use restraints to ensure the client’s safety.

speak calmly in an authoritative and neutral manner to the client.

Speaking calmly in a neutral manner can soothe an agitated client. Restraints are not appropriate for a client who is merely confused and can be placated.

A client with a terminal illness tells the nurse that he has begun praying every night. The client states, “If I pray every night, God will forgive me.” This represents which stage of grief?A. Acceptance.B. Bargaining.C. Denial.D. Anger.

Bargaining.

This patient is bargaining to be “forgiven” in order to cure his illness. This is a normal stage in the grieving process.

Which of the following pieces of assistive equipment would be most helpful in moving an immobile client from their bed to a chair?A. Transfer belt.B. Wrist restraints.C. Draw sheet.D. Hoyer lift.

Transfer belt.

The transfer belt will help staff to safely move the client because it allows for a better grip and minimizes the chance of dropping the client.

The nursing assistant prepares to give a patient a bed bath. Before turning the patient to rub their back, the nursing assistant notices that he has a Foley catheter in place. Where should the nursing assistant secure the catheter to ensure it is not pulled during the bath?A. To the medial aspect of the patient’s thigh.B. To the lateral aspect of the patient’s thigh.C. To the bed sheet.D. To the bed.

To the lateral aspect of the patient’s thigh.

Securing the catheter to the lateral aspect of the patient’s thigh ensures it cannot be painfully pulled during the bath.

A patient has just received news about the death of his spouse. He states to the nursing assistant, “I can’t believe this has happened to me. I don’t know what to do. How can I live without my wife?” The nursing assistant best responds by statingA. “This kind of thing will happen to everyone eventually.”B. “You will need more time to cope with this loss.”C. “Do you and your wife have any children together?”

D. “I understand you’re in pain. I’ll stay with you.”

“I understand you’re in pain. I’ll stay with you.”

This is the best answer because it reflects what the patient is feeling (pain) and stays with the patient to comfort him.

The nursing assistant helps a patient who recently had a right-sided stroke to bathe. Which of the following describes the BEST method to support the patient’s independence?A. Encourage the patient to do the best he can to clean himself.B. Ask the patient what he wants to do.C. Complete the entire bath for him to conserve his energy.D. Allow the patient to perform as much of the bath as possible.

Allow the patient to perform as much of the bath as possible.

It is best for the patient to perform as much of the bath as possible, with the nursing assistant helping out when necessary.

A resident comes out of their room saying they have burned their leg after they dropped hot soup on it. The skin looks blistered and red. The nurse assistant knows this is aA. partial thickness burn.B. serious burn.C. total thickness burn.D. superficial burn.

partial thickness burn.

This describes a partial thickness burn. A total thickness burn appears waxy and white, while a superficial burn might be described as blotchiness of the skin with no blistering.

A client who has not had a bowel movement in four days would receive the most benefit from which of the following procedures?A. Catheterization.B. Colonoscopy.C. Endoscopy.D. Enema.

Enema.

An enema will help the patient in expelling fecal matter before it can become impacted.