The resident is to be placed in Fowler’s position. Which of the following is the correct definition of this position?
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Solution
A. Fowlers position is the head of the bed raised at least 45 degrees with the legs bent or straight. Head of the bed flat (B) describes supine position. Bed flat with feet higher than the head (C) describes trendelenburg position. Head of bed 15 degrees with legs either bent or straight (D) describes supine position with head of the bed slightly raised.
Select the observation that should be reported to the nurse STAT?
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Solution
C. A respiratory rate of 38 is abnormal and might indicate the resident is in severe respiratory distress. Cloudy yellow urine (A), brown loose stools (B), and a radial pulse of 80 (D) need to be reported to the nurse but not immediately.
Which of following is not a sign of impending death?
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Solution
D. When a person is dying, you do not typically see stable vital signs. The blood pressure drops to
below normal; the respirations become shallow (A); the pulse becomes irregular, weak, and thready; and the skin becomes moist and cool (C).
In which of the following conditions is a cold pack applied?
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Solution
C. Cold application is used to decrease swelling. Burn injuries require moist dressings (A). Pressure is used to stop bleeding (B). Heat is used to decrease back pain (D).
When a resident falls, what is the most frequent injury that occurs?
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Solution
D. The hip is a common site for a fracture when a resident falls. Although a broken wrist (A), fractured
ankle (B), or strained ligament (C) could occur during a fall, they are not considered common sites for injury when a resident falls.
If the nursing assistant recognizes that a resident is not eating enough, he or she should do which of the following?
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Solution
A. Many of the residents have a form of dietary liquid drink order by the physician when they are not receiving enough calories. Administering vitamins to the resident (B) is considered administration of a medication and is out of the scope of the nursing assistant’s role. Providing an additional tray of food is inappropriate if the resident did not eat the first tray (C). Telling the nurse that the resident needs tube feedings is not the responsibility of the nursing assistant, but that of the physician, resident, or family (D).
Which of the following behaviors is considered a demonstration of caring?
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Solution
B. Listening to the resident when he or she is talking is a form of caring, showing value to the resident as a person. Timely completion of an assignment (A) and obtaining vital signs for the unit before lunch (C) are tasks and are not forms of caring. Not changing the resident when soiled (D) is considered neglect.
An assigned resident does not want lifesaving measures to be performed if he expires. You know the term written on the chart is which of the following?
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Solution
B. DNR is the medical abbreviation used for “do not resuscitate.” If the resident stops breathing or does not have a pulse, he or she does not want CPR or other forms of lifesaving measures to be performed. NPO is the medical abbreviation for non per os, which means nothing by mouth (A). CPR is the medical abbreviation for cardiopulmonary resuscitation (C). ADL is the medical abbreviation for activities of daily living (D).
A fellow nursing assistant comes to work under the influence of marijuana. As a member of the health-care team, your best action is which of the following?
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Solution
A. An impaired employee is more likely to be involved in an injury to self or a resident. If you are aware of anyone working who is impaired and do not report it, you could also be held responsible for a staff member’s or resident’s injury. Answers B, C, and D all involve hiding the impairment from the employer.
Which of the following is least likely to cause a skin tear?
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Solution
C. Fingernails of the nursing assistant should be kept clean and short to protect residents from scratches or tears to the skin. A ring or watch (A), friction (B), or pulling on an extremity (D) could cause the skin of an elderly resident to tear.