Which of the following is false regarding assisting a resident with his or her bath?
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Solution
D. At least two washcloths and towels will be needed. One is for clean areas and the other for areas considered dirty. This is done to prevent spread of organisms. Keeping the room free from drafts (A), assuring the resident’s privacy (B), and warming the bath water to at least room temperature (C) are correct. The room is to be free of drafts and the room temperature should be
between 68°F and 74°F to prevent chilling. Resident’s privacy is to be maintained at all times. Bath water temperature should be warm to promote comfort, help relaxation of muscles, and prevent chilling but not hot to risk injury to the resident.
The nurse assistant might expect to find pressure ulcers in all of the following locations except which of the following?
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Solution
B. Pressure ulcers are more prone to develop in bony areas. The heels (A), elbows (C), and knees (D) are areas with the highest incidence of pressure ulcers, which are located on bony surfaces.
A resident who was very talkative earlier in the day is now difficult to awaken for his bath. The most appropriate action for the nursing assistant is which of the following?
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Solution
B. Change in a resident’s condition is serious and should be communicated to the nurse immediately. (A) Asking a fellow nursing assistant is not correct because assessment of the resident is not part of the nursing assistant’s role. (C) Assumptions might lead to harm of the resident. (D) The first and most important action of the nursing assistant in this situation is to communicate immediately to the nurse the change in the resident’s condition.
Which of the following is not part of the procedure for weighing residents?
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Solution
C. Residents should be weighed at approximately the same time each day. Having the resident remove shoes (A) and voiding (B) before being weighed, and calibrating the scales to zero each day or routinely (D) are part of the procedure for assuring accurate weighing of the residents.
Which blood pressure should the nursing assistant repeat before reporting it to the nurse?
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Solution
A. Normal blood pressure for an adult is less than 120/80 and pre-hypertensive is less than 139/89. The blood pressure readings of 120/74 mm Hg, 140/68 mm Hg, and 130/70 mm Hg in choices B, C, and D are within normal limits.
Which statement is true?
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Solution
D. Bradycardia is the heart rate below 60 beats per minute. Tachycardia is a slow heart rate (A) is incorrect; Tachycardia is the heart rate above 100 beats per minute. An irregular heart rate should be taken for at least 30 seconds (B) is an incorrect statement because irregular heart rates are to be obtained for one full minute. The carotid site is used most often to obtain the pulse (C) is incorrect; the radial site is used most often to obtain a resident’s pulse.
Which of the following apical pulse rates should be repeated?
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Solution
B. The normal adult heart rate is between 60 to 100 beats per minute. A pulse rate of 84 (A), 76 (C), and 66 (D) are within the normal range.
Which statement about taking an oral temperature is false?
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Solution
C. Normal oral temperatures are between 96.8°F and 100.4°F. Placing the thermometer in the mouth under the tongue in the sublingual pocket (A), waiting 10 minutes if the resident has consumed any hot or cold liquids (B), and using thermometer covers on all residents (D) are all steps used to determine the oral temperature.
The nurse hands the nurse assistant a tube of medication and asks her to apply it after she has completed the resident’s bath. Which of the following would be the nursing assistant’s best response?
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Solution
D. Nursing assistants are not to apply medications, because they do not have a license, training, or knowledge to administer medications. The statements in choices A and C are incorrect because the nursing assistant is planning to administer the medication, which is not part of his or her role. The statement in choice B is incorrect due to the use of improper communication.
Which of the following are two general goals for a.m. care?
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Solution
D. The two primary goals of bathing is protection from harmful bacteria and promoting the wellbeing of the residents. Removing soil and promoting an increase in skin moisture (A) is incorrect because bathing might increase skin dryness, not decrease it. Promoting relaxation of the resident and decreasing need for mobility (B) is incorrect because residents require mobility to decrease morbidity. Increasing circulation and decreasing incidence of pressure ulcers (C) is incorrect because pressure ulcers are decreased by cleanliness and frequent change of position along with proper nutrition.