CNA Basic Nursing Skills 2

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Normal urine color is

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Normal urine has a yellow color that ranges from dark yellow to light straw color. Urine that is amber-colored indicates dehydration; more fluids need to be taken. Brown urine can mean severe dehydration or liver disease, and should be checked. Urine that is red-tinted can happen after the client eats some foods, such as beets or blueberries. Red urine can also be a sign of kidney disease, urinary tract infections, or prostrate problems. If urine is colorless, it can mean that the client is over-hydrated and should reduce fluid intake.

Signs and symptoms of shock may include

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Signs of shock include low blood pressure (hypotension), a rapid heart rate (tachycardia), a weak pulse, and pale skin which can be damp or clammy. The client may also be breathing rapidly (hyperventilation). The client may also be confused or not alert. Shock is an emergency situation, requiring rapid treatment.

What is the best way of keeping a skilled nursing facility from having an unpleasant odor?

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All staff in a skilled nursing facility are responsible for maintaining a pleasant environment. Any source of odor must be dealt with at once. Bedpans and commodes should be emptied and cleaned as soon as the client finishes. All linens should be changed per the facility's policies and as needed. Soiled linens should be transferred to the laundry facilities as soon as possible. Housekeeping can clean the common areas, dining room, and client rooms to prevent odors from food or incontinent episodes.

The brain is part of the

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The nervous system has two parts. The brain and spinal cord make the central nervous system (CNS). The peripheral nervous system (PNS) is made up of all the body's nerves, which connect to the CNS. The brain sends messages through the spinal cord and nerves to control the body's muscles and organs. It also processes and interprets the information from both inside and outside the body.

While taking a rectal temperature the nurse aide should insert the thermometer and

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A rectal temperature is the most accurate, but needs to be done correctly. After placing the client in Sim's position, lubricate the thermometer and gently insert it about one or two inches into the rectum. Hold the thermometer in place for two minutes to prevent it being pushed out or advancing into the rectum. After withdrawing it, wipe it with a gauze pad, read the temperature, and place the thermometer in the "used" container.

Which of the following should be reported immediately?

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A low blood pressure (hypotension) is less than 90/60. Only one of the numbers has to be lower to be considered hypotension. Some clients may have a normal blood pressure in the low range, but if there is a sudden drop from usual, immediately report it to the nurse.

A patient has a diagnosis of psoriasis. Her nurse aide should

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Auto-immune diseases are never contagious. They happen when the body's defense (immune) system attacks its own healthy tissue by mistake. Besides psoriasis, other examples of an auto-immune disease are lupus, celiac disease, multiple sclerosis, and type 1 diabetes. Client care is the same as for any other client without an auto-immune disease.

A professional and safe working appearance would include

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The nurse aide is considered to be a health care professional and should dress accordingly. Each facility has a dress code policy regarding the type of uniform to wear. Clothing must be clean and free from stains, tears, or wrinkles. Shoes must be closed-toe, with non-skid soles. Appropriate grooming is always necessary. Jewelry is usually limited to a watch and wedding ring, to avoid injuring a client while giving care. A name tag is part of the standard uniform.

The recommended position for giving an enema is

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The left Sim's position is used for rectal examinations and administering enemas. The client lies on the left side, with the right knee and hip bent. It is also called the lateral recumbent or semiprone side position.

A nurse assistant notices red marks on a resident’s back and buttocks. The aide acts in the knowledge that

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A reddened area is the first sign of skin breakdown. It means that there is pressure and a lack of blood circulation to the area. The nurse aide should immediately reposition the client to eliminate pressure. Clients who are not mobile need to be repositioned at least every two hours. Never massage a reddened area, as this will increase the damage. Keep the client clean from perspiration, urine, and feces. Continue to observe the skin and report to the nurse if the marks do not quickly disappear.

Most of our calories should come from

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A balanced diet is essential for health. When nutrients are taken in the right combination of calories, the client's desired weight is maintained. Carbohydrates supply fuel for the body, so 45-65% of calories should come from carbohydrates. The energy is stored in the muscles and the liver for immediate or future use, as well as for the brain to function. Fat and protein have important roles, but are not good for energy sources.

To help ensure adequate circulation to prevent skin breakdown, you could

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One of the primary responsibilities of a nurse aide is to monitor the client's skin for any signs of breakdown. During baths, dressing, or position changes, inspect the skin for redness, pallor, warmth, or bruising. Reposition at least every two hours, protecting areas that rub together, as well as the bony prominences. Massages to the back and buttocks can promote circulation. Range-of-motion exercises are also helpful. Always report any signs of breakdown to the nurse.

Before performing any procedure a nurse aide must

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Clinical standards state that all health care professionals must identify the client by checking the ID band or tag before providing care. They should wash their hands before and after an encounter with a client. They should also explain what they are going to do and give the client an opportunity to ask questions before proceeding.

In the Nursing Care Plan you note it is written; “O2 per N/C @3L, Orthopnea pos. as needed”. As a CNA you know this means

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This nursing care plan means that the client is receiving oxygen at a constant rate of 3 liters per minute, using a nasal cannula. If the client has difficulty breathing, the CNA can assist the client to sit in a Fowler's (upright) position. Every facility has a list of approved abbreviations. The CNA should become familiar with these, for reading care plans and for doing documentation.

In report the nurse aide is told that one of her patients has been ordered NPO after midnight. The aide should

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NPO is a common medical term that means the client can not eat or drink anything, including water or ice chips. A doctor orders a patient to be NPO at midnight for situations such as before surgery or certain lab work. The nurse aide can provide mouth care for a client who is NPO. Placing a "NPO" sign over the client's bed and on the client's door will remind all staff members not to give the client anything to eat or drink.

The charge nurse has asked you to take Mrs. Shumway's vital signs. You know you must first

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Before providing any care, the nurse aide must follow all the standard steps in preparation. ALL of the steps must be taken before proceeding, not just one. Gather everything needed, so that you don't have to leave the client's room once you begin. Handwashing is always done before and after each client interaction. Knocking before entering the client's room, introducing yourself, identifying the client, and explaining what you will be doing are also part of standard practice.

Meal trays have arrived. Before serving each tray the nurse aide should

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Before serving a meal tray, always check the client's ID band or tag and match it with the correct tray. Some clients have special diets, severe food allergies, or strict fluid restrictions. While it can be tempting to skip this step in a long-term care facility, the nurse aide is legally responsible for verifying the identity of each client before serving food or giving care.

Which of the following measurements you obtained from Mrs. Shumway should be reported immediately to the charge nurse?

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Hypertension is defined as a blood pressure over 140/90. Severe hypertension is above 180/120. Even if the client has a history of high blood pressure, always immediately report a sudden increase to the nurse. Untreated hypertension can lead to heart disease and stroke.

A patient complains that her hand hurts where the IV is running. The nurse assistant notices that the hand is puffy. The best thing to do is

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Infiltration happens when the IV fluid leaks into the tissue because of a dislodged or misplaced IV catheter . The nurse assistant should monitor the IV site and report if it becomes swollen, cool to the touch, or painful. The skin near the IV site may look pale. Always be careful when moving or assisting a client with an IV to avoid pulling the line.

Who orders a warm or cold application?

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It is important to remember that only a doctor can order a treatment, test, or medication for a client. This includes simple treatments, such as hot and cold compresses. A nurse aide can be fired or lose certification for initiating treatments.

You are caring for Mr. Brown who has a diagnosis of COPD. His SpO2 is 82%. He is currently receiving O2 via Nasal Cannula @ 2 liters/min. What do you do?

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The normal SpO2 range for a client with Chronic Obstructive Pulmonary Disease (COPD) is 88-92%. This is because oxygen reaches the lungs, but lung damage prevents oxygen from getting into the blood. Giving oxygen is carefully regulated for clients with COPD, with limits according to how the oxygen is delivered. Immediately report a low saturation to the nurse. Do not make any changes on your own.

Your resident consumed a bowl of soup that was 180 cc of liquid. How many ounces was that?

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180 cc = 6 oz. When converting cubic centimeters (cc) to ounces (oz) remember that 30 cc= 1 ounce. Although an ounce is slightly more, the amounts are considered to be equal by doctors and pharmacists. Also, 1 cc = 1 ml.

The circulatory system consists of the

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The circulatory system is made up of the heart, arteries, veins, and capillaries. They are connected to make a complete circuit in the body. The heart pumps oxygenated blood from the lungs, as well as nutrients, through the arteries to the capillaries. The capillaries then deliver carbon dioxide and waste to the veins. The veins take the waste products to the liver and kidneys for disposal, and the carbon dioxide goes to the lungs to be exhaled.

A nurse aide notices blood in a patient’s IV tubing. The aide should

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When an IV is running well, the tubing should be clear and the IV site clean and dry. If blood is noted in the tubing, notify the nurse. It is beyond the scope of practice for a nurse aide to do anything with an IV.

Continuing education is

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Learning for health care professionals does not end at graduation. Medicine is constantly changing, and it the responsibility of each person to be aware of new developments in their area of practice. Clinical standards and many states require proof of continuing education in order to renew a license or certification. During an accreditation survey, hospitals and facilities must show proof that staff members receive ongoing training and education.

The opening of the colostomy to the outside of the body is called the

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A stoma is an artificial opening in the body, done during surgery. For a client with a colostomy, the surgeon brings the end of the colon through the abdomen and creates a mouthlike opening that will drain waste into a bag. A stoma can also be done for the bladder and for the ileum (the lowest part of the small intestine).

Post-partum refers to

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Post-partum is the medical term that means "after giving birth." The prefix "post" always means after in any medical term. For example, post-operatively means "after surgery" and post-discharge means "after leaving treatment." The term "partum" refers to giving birth.

Mrs. Shumway's nursing care plan lists CHF (Congestive Heart Failure) as her primary dx. (diagnosis). You would expect her ADL routine to include

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Congestive heart failure is a chronic disease that happens when the heart becomes weak and is unable to pump efficiently. It is important to monitor the client's weight, because sudden weight gain means that the client is retaining fluid. This puts a strain on the heart and lungs. The nurse aide should weigh the client every morning at the same time and record the weight. Notify the nurse of any sudden change.

A patient appears more pale than usual. The nurse aide should

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Whenever noticing any change in the client's condition, stop to assess the client and take vital signs. If the client is able to respond, ask how the client feels. Report the change, vital signs, and client's response to the nurse. When charting, document what you observed and did.

A patient who was given insulin in the morning is pale and sweaty and appears confused two hours later. It would be helpful to find out whether the patient

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Diabetic clients have a strict schedule regarding insulin injections and eating. Eating causes blood sugar to rise, and the insulin helps move it into the cells. Without food, the blood sugar drops quickly, causing a serious situation. Immediate treatment is necessary. Quickly check the client's blood sugar and report it to the nurse. The client will need to eat 15 grams of glucose or a simple carbohydrate, such as 1/2 cup orange juice or a Tablespoon of sugar. The nurse aide should be aware of which clients are diabetic so that meals are served shortly after receiving insulin.

When caring for a resident with an indwelling Foley catheter it is important to

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When a client has an indwelling Foley catheter, the nurse aide should check that the tubing is open so that the urine can flow from the bladder. After each position change or when the client returns to the bed or chair after being up, ensure that the tubing is not kinked or closed. The bag should be lower than the bladder to prevent backflow.

Mrs. Hernandez had a hip replacement and is admitted to the long term care facility for rehabilitation. Her condition is

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An acute event is a new or sudden situation that is expected to resolve. Examples are a broken bone, a head cold or the flu, or an asthma attack. In this question, Mrs. Hernandez has an acute condition because she will be leaving the long-term care facility after she finishes rehabilitation. A chronic condition develops slowly and continues to progress. Examples are heart disease, diabetes, and osteoporosis.

On what side should the patient lie for an enema?

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The left Sim's position is used for rectal examinations and administering enemas. The client lies on the left side, with the right knee and hip bent. It is also called the lateral recumbent or semiprone side position.

A resident with an ileostomy evacuates feces through the

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The ileum is the lowest part of the small intestine. An ileostomy is an opening in the abdomen that is made during surgery. The end of the ileum is placed outside the body and connected to a bag that collects the waste of the intestine. It is usually on the lower right side of the body.

Drainage bags from urinary catheters should always

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Drainage bags from an indwelling Foley catheter should be kept below the the level of the bladder to prevent urine from backflowing into the bladder. It also allows gravity to help drain the tubing. Checked that the tubing is not kinked or compressed. Depending on the reason for the catheter, urine may have an unusual appearance; ask the nurse what is abnormal for the patient. Monitor and record the color of the urine, as well as observations such as sediment, cloudiness, or blood. Follow your facility's policy or the patient's care plan regarding how often to change the urinary drainage bag.

Which of the following is associated with smoking?

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The effects of smoking can cause many diseases and medical complications. While cigarette smoking is the main cause of lung cancer, it also causes other lung conditions such as COPD, emphysema, and pneumonia. Smokers are more likely to develop heart disease and have heart attacks and strokes. Vitamins are depleted in smokers, especially vitamin C and the B vitamins.

Mrs. Sparks is an 83-year-old female patient who suffers from the late effects of a CVA. she has {L} sided hemiplegia. This is

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A client with left-sided hemiplegia has paralysis on the left side of the body. The paralysis can be partial or total. It occurs on the opposite side of the CVA (stroke) or brain disorder. Mrs. Sparks had a CVA on the right side of her brain, resulting in left-sided paralysis.

Which of the following is not true of blindness?

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People who are legally blind or have visual impairment may still be able to see, but images can be quite blurry even when wearing glasses. They have difficulty reading and are restricted from such activities as driving. Another disability is related to having tunnel vision, which means the person can only see straight ahead instead of the normal ability to use peripheral vision to see almost 180 degrees. Only about 10-15% of people who are diagnosed as blind see nothing at all.

Mrs. Shumway has an order for I&O. You have picked up her breakfast and note she drank half of a 6oz. glass of juice, 4oz. of milk, and 8oz. of coffee, you document

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The question is about HALF of a 6oz. glass. 15 oz. = 450 cc. When converting ounces (oz.) to cubic centimeters (cc) remember that 1 oz. = 30 cc. Although an ounce is slightly more, the amounts are considered to be equal by doctors and pharmacists. Also, 1 cc = 1 ml.

The safest way to confirm a resident’s identity is

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Accurate identification of a resident is always done by checking the resident's ID bracelet or tag. This is a universal standard of practice in every facility and health care setting. It ensures that the resident receives the correct treatment and care every time.


CNA Basic Nursing Skills

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