Nurse Aide Guidelines: Best Practices for Client Care, Exams of Nursing

Download Nurse Aide Guidelines: Best Practices for Client Care and more Exams Nursing in PDF only on Docsity! NNAAP Nurse Aide Practice Exam Questions and SOLUTIONs What is the term for a device used to take the place of a missing body part? - SOLUTION- Prosthesis When a client has left-sided weakness, what is the recommended part of the sweater to put on first? - SOLUTION-Left sleeve It is appropriate for a nurse aide to share the information regarding a client's status with: - SOLUTION-the staff on the next shift When helping a client who is recovering from a stroke to walk, the nurse aide should assist: - SOLUTION-on the client's weak side The nurse aide is caring for a client who is agitated. The nurse aide SHOULD: - SOLUTION-talk in a slow, calm, reassuring manner Exercises that move each muscle and joint are called: - SOLUTION-range of motion How can the nurse aide BEST help a client who is not accepting loss? - SOLUTION- Encourage the client to talk To BEST communicate with a client who is totally deaf, the nurse aide should: - SOLUTION-write out information The nurse aide is asked by a confused client what day it is. The nurse aide should: - SOLUTION-point to the date on the calendar and say the date To avoid pulling the catheter when turning a male client, the catheter tube must be taped to the client's: - SOLUTION-upper thigh A nurse aide can assist clients with their spiritual needs by: - SOLUTION- allowing clients to talk about their beliefs A nurse aide MUST wear gloves when: - SOLUTION-doing peri-care When getting ready to dress a client, the nurse aide SHOULD: - SOLUTION-give the client a choice of what to wear If the nurse aide discovers fire in a client's room, the FIRST thing to do is: - SOLUTION- remove the client In order to communicate clearly with a client who has hearing loss, the nurse aide should: - SOLUTION-look directly at the client when speaking Which of the following stages of dying usually is the final stage? - SOLUTION- Acceptance If a client says, "God is punishing me" or "Why me?", how should the nurse aide respond? - SOLUTION-Listen quietly The role of the ombudsman is to: - SOLUTION-work with the nursing home to protect the clients' rights A nurse aide who is active in her church is assigned to care for a client who is not a member of any religious group. The nurse aide SHOULD: - SOLUTION-respect the clients beliefs and avoid starting religious discussions The nurse aide notices that a client's mail has been delivered to the client's room. The nurse aide SHOULD: - SOLUTION-give the client the unopened mail and offer help as needed Which of the following is a correct measurement of urinary output? - SOLUTION-300 ml All of the following situations are examples of abuse or neglect EXCEPT: - SOLUTION- restraining a client according to a physician's order A) threatening to withhold a client's meals C) leaving a client alone in a bathtub D)leaving a client in a wet and soiled bed If a client is sitting in a chair in his room masturbating, the nurse aide SHOULD: - SOLUTION-leave the client alone and provide privacy To convert four ounces of juice to milliliters (ml), the nurse aide should multiply: - SOLUTION-4 x 30 ml In giving care according to the client's Bill of Rights, the nurse aide SHOULD: - SOLUTION-provide privacy during the client's personal care A client wakes up during the night and asks for something to eat. The nurse aide SHOULD: - SOLUTION-check the client's diet before offering nourishment The normal aging process is BEST defined as the time when: - SOLUTION- normal body functions and senses decline If a client is confused, the nurse aide should: - SOLUTION-help the client to The nurse aide is in the employee dining room. A group of nurse aides are eating lunch together and begin discussing how rude a certain client was acting. The nurse aide SHOULD: - SOLUTION-suggest that this is not the place to discuss the client The nurse aide enters a client's room, and the client states that he has pain. What should the nurse aide do? - SOLUTION-Report it to the nurse in charge A client is upset and crying over the recent death of her husband. How should the nurse aide respond? - SOLUTION-Sit with the client and allow her to talk about her feelings What is the beginning sign of a pressure sore? - SOLUTION-Discoloration While assisting a client with denture care the nurse aide observes that the upper plate is cracked. The nurse aide SHOULD: - SOLUTION-report the damage to the nurse in charge A new client declines the offer to wear a clothing protector at lunch. The nurse aide SHOULD: - SOLUTION-respect the client's wishes The nurse aide can BEST show that he is listening to the client by: - SOLUTION- responding when appropriate The purpose of padding side rails on the clients bed is to? - SOLUTION-Protect the client from injury. The Heimlich Maneuver (Abdominal thrust) is used for a client who has? - SOLUTION-A Blocked airway. The client offers a nurse aide a twenty dollar bill as a thank you for all that the nurse aide has done. The nurse aide should? - SOLUTION-Politely refuse the money. To prevent the spread of infection, how should the nurse aide handle the soiled linens removed from a client's bed? - SOLUTION-Put them in the dirty linen container How many tips does a quad-cane base have? - SOLUTION-Four. A safety device used to assist a DEPENDENT client from a bed to a chair is called a? - SOLUTION-Transfer/gait belt. Which temperature is considered MOST accurate? - SOLUTION-Rectal. The BEST time to prepare for a disaster is? - SOLUTION-Before it happens. What is the purpose of the federal law OBRA, 1987-Ominibus Budget Reconciliation Act? - SOLUTION-Protect the rights and privileges of people, to adopt standards for nursing assistant training, and to provide legal standard (the lowest standard of behavior). What are the local / state resources for client advocacy? - SOLUTION- Ombudsman program- long tern care, Bureau of Quality Assurance, and the coalition for advocacy- for mental/ developmental disabled clients. How often is the State Survey (Bureau of Quality Assurance) done? - SOLUTION-It is done every 9-12 months (any shift) - more frequently if deficiencies are present. What is the focus of the State Survey (Bureau of Quality Assurance)? - SOLUTION- Abuse, Dignity, Weight loss and hydration, infection control, falls, and pressure sores. If a nurse aide is questioned by a State Surveyor what should they do? - SOLUTION- SOLUTION the question asked honestly. Cardinal Rules to Protect Residents from Abuse (RAGE)? - SOLUTION-Remove resident from harm, Alert supervisor immediately, Give statement of Witnessed abuse, Everytime you witness Verbal or Physical Abuse. What is Negligence? - SOLUTION-Failure to give care that is reasonably expected. Examples of Negligence? - SOLUTION-Failure to follow the individual care plan, To ignore or disregard a client's request or needs, Failure to SOLUTION a call light promptly, and failure to carry out an expected or required duty either through carelessness or by intention. What is abuse? - SOLUTION-To treat badly, to injure, berate, insult, or mistreat. Examples of abuse? - SOLUTION-Striking a client, Using profanity or name calling, restraining clients for the convenience of staff, withholding food as a punishment, inflicting pain or mental anguish, excessive use of drugs, and harassment. What is assault? - SOLUTION-A threat or an attempt to commit bodily harm. Examples of assault? - SOLUTION-Shaking a fist at a client or threatening to use a restraint for punishment. What is Battery? - SOLUTION-An assault that is carried out such as punching or hitting a client or the unnecessary rough handling of a client. What is slander? - SOLUTION-Gossip or saying untruths. What is Libel? - SOLUTION-Defamation of character in writing, signs or pictures. False documentation or drawing a degrading picture. What is airborne transmission? - SOLUTION-Spread of evaporated droplets or dust particles that contain the infectious microorganism which can be spread through the air and inhaled. What is droplet transmission? - SOLUTION-Spread of droplets ejected from the mouth or nose during coughing, sneezing, or talking. What are standard precautions? - SOLUTION-Practices to prevent exposure to all clients' blood, body fluids, non-intact skin, and mucus membranes. What is Personal Protective Equipment(PPE)? - SOLUTION-Specialized clothing, equipment, or barriers used to prevent exposure to blood, body fluids, non-intact skin, and mucous membranes for example gloves, goggles, masks, gowns. What is Disinfection? - SOLUTION-Process by which pathogens are destroyed - kills most microorganisms - 1:10 ratio bleach and water. What is Sterilization? - SOLUTION-The process by which all microorganisms and their spores are destroyed. What is isolation? - SOLUTION-Specific precautions to prevent the spread of communicable disease. What is a communicable disease? - SOLUTION-Disease caused by pathogens that are easily spread. What is common vehicle transmission? - SOLUTION-Applies to microorganisms transmitted by contaminated items such as food, water, medications, devices, and equipment. What is Vectorborne transmission? - SOLUTION-This occurs when vectors such as mosquitoes, flies, ticks, and vermin transmit microorganisms such as west nile or lymes disease. What is cross infection? - SOLUTION-The spread of infection from one person to another. What is OSHA? - SOLUTION-Occupational Safety and Health Administration- government agency regulating employee safety. What is MSDS? - SOLUTION-Material Safety Data Sheets - listing of potentially hazardous chemicals used in the workplace; this listing explains proper use, dilution, precautions to take (PPE) , clean up and disposal procedures, and first aid measures for exposure. What is MRSA? - SOLUTION-Methicillin Resistant Staphylococcus Aureus - strong infection. What is VRE? - SOLUTION-Vancomycin Resistant Enterococcus. What is the number one way diseases are spread? - SOLUTION-By not washing your hands. In the Chain of Infection what must be present for disease to occur and spread? - SOLUTION-An infectious agent, a Reservoir(host), A portal of exit, a mode of transmission, a portal of entry, and a susceptible host. What is a bloodborne pathogen? - SOLUTION-A bloodborne pathogen is a disease microbe that is transmitted through blood or other body fluids such as blood, semen, vaginal secretions, and cerebrospinal fluid. Common diseases caused by bloodborne pathogens? - SOLUTION-Hepatitis - A,B, C, D, and E and HIV. Conditions favorable to growth of microorganisms? - SOLUTION-Warmth, oxygen-can be anaerobic or aerobic, darkness, nourishment, and moisture. Elements needed for effective handwashing? - SOLUTION-Running water, soap, and friction. When are gloves worn? - SOLUTION-When contact is likely with blood/body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes. When touching soiled dressings, tissues, linens etc... Between procedures on the same client. When is protective clothing and eyewear worn (i.e. gowns, aprons, masks goggles)? - SOLUTION-During situations where exposure to blood/body fluids is possible. Areas considered clean? - SOLUTION-Linen room/cart, treatment/supply room, overbed table, top drawer and top shelf in bedside table, and food cart prior to all trays being served. Areas considered dirty? - SOLUTION-Floor, Bottom shelf of bedside stand, seat of chair in client's room, toileting areas, soiled utility room, sinks, door handles/knobs, linen hampers, nursing assistants uniform. What is routine isolation? - SOLUTION-Keeps germs inside the clients room. What is Reverse (protective) Isolation? - SOLUTION-Keeps germs outside the client's room. What is respiratory arrest? - SOLUTION-Condition where breathing has stopped. What is Cardiac arrest? - SOLUTION-Condition where the heart stops beating. What is aspiration? - SOLUTION-Accidental inhalation of foreign material (like foods, liquids, vomitus) into the airway. What is the Heimlich maneuver? - SOLUTION-Abdominal thrusts used to clear an obstructed airway in an adult or child older than 1 year. What is hemorrhaging? - SOLUTION-Excessive loss of blood in a short time. What is choking? - SOLUTION-An airway obstruction. What are the signs of a partial airway obstruction? - SOLUTION-Person may have foreign object in throat but still may be capable of some air exchange. If a person is able to cough or talk. If coughing diminishes and a wheezing gurgling noise are heard -do the Heimlich maneuver. What are the signs of complete airway obstruction? - SOLUTION-Inability to speak or cough, Person grasps neck and opens mouth to indicate inability to breathe, no coughing or sounds heard from airway, and skin color change to bluish gray or dusky color. What should you do if a fall occurs? - SOLUTION-Stay with your resident, do not move them, Call for help from the nurse on duty, and complete an incident report. What is the role of the nurse aide in any emergency? - SOLUTION-Recognize emergency, Action - stay calm and assess the situation, Stay with the client, Call for nurse, Follow the nurse's instructions, provide care until EMS arrives, Do not offer food or fluids, and document - incident report. Fire - What are the elements needed for combustion? - SOLUTION-Fuel, Heat, and O2. What does RACE stand for? - SOLUTION-Rescue/Remove all Patients, Activate the Alarm, Confine-close doors and windows, and Extinguish if possible. What should you remember concerning the basic use of a fire extinguisher? - SOLUTION-PASS. Pull Safety Pin, Aim the nozzle, Squeeze the handle, Sweep from side to side on the flames. What is supine? - SOLUTION-Lying on the back, face up. What is prone? - SOLUTION-Lying face down. What is dangle? - SOLUTION-To sit on the edge of the bed. What is ambulatory? - SOLUTION-Able to Walk. How long should restraints be removed and how frequently? - SOLUTION- Remove restraints every 2 hours for at least 10 minutes. What is range of motion? - SOLUTION-The movement of a joint to the extent possible without causing pain. What is the purpose of performing range of motion? - SOLUTION-Maintain joint mobility, prevent loss of function, increase mobility in a joint, and improve circulation of an extremity. What are the types of R.O.M.? - SOLUTION-Passive (R.O.M done for the client by another), Active (R.O.M. done by the client independently), and Active Assist (R.O.M. done by the client with some assistance from the rehabilitative team member.) What is abduction? - SOLUTION-To move a body part away from the body. What is Adduction? - SOLUTION-To move a body part towards the body. What is the body's first line of defense against disease? - SOLUTION-Skin. What is oral Hygiene? - SOLUTION-Care of the mouth and teeth and gums. What does P.O. cares stand for? - SOLUTION-Oral Care. What does indentureless mean? - SOLUTION-Without teeth. What position should a client being in when receiving oral care? - SOLUTION- Sitting up. What is a complete bed bath? - SOLUTION-Bathing the entire body with or without shampoo. What is a partial bed bath? - SOLUTION-Involves body areas that have a greater tendency of developing odors- it is done daily - cleanest to dirtiest - eyes and face-no soap, under breasts, axilla - under arms, perineal, perianal, and assess if nail care should be done. What does DNR stand for? - SOLUTION-Do not resuscitate. What to do if a client has a seizure. - SOLUTION-Protect them from injuring themselves, keep airway open, and after the seizure place the client on his side. What to do if a client is bleeding. - SOLUTION-Try to find out what area is bleeding, raise the affected parts above the head when possible, apply pressure dressing, if it is an embedded object -do not remove. What is perineal Care? - SOLUTION-Cleaning the genital and anal areas of the body. Clothing should be removed from what side first? - SOLUTION- Remove from the strongest side first. Clothing should be put on from what side first? - SOLUTION-Put clothing on the weakest side first. What is dehydration? - SOLUTION-Too little fluid in the body. What is edema? - SOLUTION-Swelling caused by excessive fluids in tissues of the body. What is dysphagia? - SOLUTION-Difficulty swallowing. What is diaphoresis? - SOLUTION-Profuse sweating. What is nutrition? - SOLUTION-The process by which the body uses food for growth and repair to maintain health. What are the 6 basic nutrients ? - SOLUTION-Carbohydrates, proteins, and fat supply energy. Minerals, vitamins, and water regulate body processes. What are some special orders for fluid balance? - SOLUTION-Encourage (push) fluids / Restrict fluids (give only what is on the tray or as directed / NPO (hold all fluids/food for now). What is incontinence? - SOLUTION-An inability to control urinary and or fecal elimination; may be temporary or permanent. What is stoma? - SOLUTION-An artificial opening. What is ostomy? - SOLUTION-An alternative way of eliminating feces from the body. What is ileostomy? - SOLUTION-Created with part of the small intestine - the entire large intestine or colon has been removed. What is a colostomy? - SOLUTION-Created from part of the large intestine the colon is still present. What is an indwelling catheter? - SOLUTION-A catheter that is left inside the bladder to provide continuous urinary drainage - also called a foley catheter. What is a suprapubic catheter? - SOLUTION-A catheter that is surgically inserted directly into the bladder through the abdominal wall, right above the pubic bone. What is a straight catheter? - SOLUTION-A catheter that is inserted and removed after urine has been drained out or specimen collected. What is an enema? - SOLUTION-The introduction of fluid into the large intestine via the anus to promote elimination of stool. What is a suppository? - SOLUTION-Medication inserted into an opening of the body. What is fecal impaction? - SOLUTION-Large mass of dry, hard stool that can develop in the rectum due to chronic constipation. What are the factors that influence elimination? - SOLUTION-Diet, fluids, activity, medications, privacy, illness, disease, disabilities, and pain. What is the bodies way of eliminating waste from the bloodstream? - SOLUTION-Urine. What are the types of urinary incontinence- temporary or permanent? - SOLUTION- Stress-coughing, sneezing, exercise / urge, functional, reflex, and overflow- urinary retention-cannot go on their own - need a catheter. What removes waste from the digestive system, is formed in the intestines and is temporarily stored in the rectum? - SOLUTION-Stool. What causes fecal incontinence - temporary or permanent? - SOLUTION- Severe diarrhea, person who is unconscious, dementia patients develop in later stages. How often should clients be checked for toileting needs? - SOLUTION-Every 2 hours. What should urine and stool be observed for? - SOLUTION-COCA - color, odor, consistency, and amount. Urine is measured in ? - SOLUTION-CC's Stool is measured in? - SOLUTION-Small, med, large, extra large. At what level should the tubing and bag of a catheter be kept? - SOLUTION- Keep tubing above level of the bag and the bag below level of the bladder. When should the catheter bag be emptied? - SOLUTION-Empty at the end of shift. What do vital signs measure? - SOLUTION-How the body is doing - temperature, pulse, respiration, blood pressure. What is the axillary temperature? - SOLUTION-Measured in the armpit (96.6 - 98.6 normal) it is the least accurate. What are some physical changes to a client's cardiovascular system in aging? - SOLUTION-Heart muscle is less efficient so decreased circulation, increased pooling of blood. Loss of elasticity in vessels results in decreased control of blood pressure. Decreased number of red blood cells - client tires easily. Decreased number of white blood cells. What are some changes to the respiratory system in aging? - SOLUTION- Lungs are less elastic they don't expand as deeply. What are some changes to the digestive system in aging? - SOLUTION- Decrease in peristalsis- food moves through slower, increases risk of constipation. Decrease in saliva, stomach acid and digestive enzymes all decrease digestion time and make chewing and swallowing more difficult. What are some changes to the urinary system in aging? - SOLUTION- Decrease of muscle tone in bladder increases chance for stress incontinence. Less filtration of wastes from kidneys increases risk of medication toxicity. Incomplete emptying of the bladder raises risk of urinary tract infections. What are some changes to the endocrine system with aging? - SOLUTION- Menopause in women and decreased sex drive in men, decrease in secretions from thyroid gland slow metabolism. What is rehabilitation? - SOLUTION-Rehabilitation is the restoration of the client to the fullest physical, mental, social, and economic functioning as possible and preventing further complications. What is the definition of a disability? - SOLUTION-Impaired physical, cognitive and or emotional function, limitations that represent a significant disadvantage in society. What is paraplegia? - SOLUTION-Paralysis of the lower half of the body. What is quadriplegia? - SOLUTION-Paralysis (partial or complete ) of all 4 extremities; the level at which the spinal cord is injured determines the amount of paralysis. What is hemiplegia? - SOLUTION-Paralysis or weakness on one side of the body often seen with persons who have had a stroke. What is a myocardial infarction? - SOLUTION-Heart attack. Signs and symptoms of a heart attack? - SOLUTION-Pain, fullness, and/or squeezing sensation of the chest, jaw pain, toothache, headache, shortness of breath, nausea, vomiting, sweating, heartburn, indigestion, arm pain, upper back pain, general malaise- vague feeling of illness. What is congestive heart failure? - SOLUTION-Reduction in the ability of the heart muscles to contract. What is arrhythmia? - SOLUTION-It is a disturbance in the regular rhythm of the heartbeat. Several forms of arrhythmia are life threatening and a medical emergency. What is Cancer? - SOLUTION-An overgrowth of abnormal cells. What is T.I.A.? - SOLUTION-Transient Ischemic Attack. Signs and symptoms of a stroke. What is diabetes mellitus? - SOLUTION-A Disease where either enough insulin is not produced, or cells are no longer receptive to the insulin. Blood sugar levels are high. What is COPD? - SOLUTION-Chronic Obstructive Pulmonary Disease. What is Osteoarthritis? - SOLUTION-Deterioration of joint cartilage and formation of new bone at joint. What is Rheumatoid Arthritis? - SOLUTION-An autoimmune disorder where the body attacks itself. What is Parkinson's disease? - SOLUTION-A slow, progressive, degenerative disorder of the central nervous system. Primary features TRAP - Tremors at rest, Rigidity and Rest, Akinesia (loss or impairment of movement) and Postural Instability (lose balance frequently and quickly). What is Multiple Sclerosis? - SOLUTION-A progressive disorder of the central nervous system (brain and spinal cord); nerves are unable to communicate with one another. What is dementia? - SOLUTION-A permanent and progressive loss of cognitive function - irreversible. What is delirium? - SOLUTION-A temporary state of confusion due to underlying cause; reversible once cause is identified. What is Alzheimer's Disease? - SOLUTION-An age related, irreversible brain disorder that develops gradually, but progressively and results in memory loss, behavioral and personality changes and eventual cause in all cognitive functions. What are the stages of Grief? - SOLUTION-Denial, Anger, Bargaining, Depression, and Acceptance What cares are performed to a client's body by the nurse aide after a client passes away? - SOLUTION-Close the client's eyes, the body is carefully bathed using gloves, all tubing and dressings are removed as directed by the nurse and clean dressings are