CNA Basic Nursing Skills 5
When calculating total fluid intake during a 24 hour period, all of the following should be included EXCEPT
Intake and output measure the fluid balance in the body. To calculate input, add all liquids, plus foods that are liquid at room temperature, such as ice cream, ice pops and jello. Pudding is also included, because it is mostly milk.
A patient has just finished taking a cold beverage. How long should you wait before taking an oral temperature?
To take an oral temperature, make sure the client has not had anything hot or cold to eat or drink, and has not smoked, for 15-20 minutes. Place the thermometer under the client's tongue. A digital thermometer will beep when it registers the client's temperature. A glass thermometer will have a line that stops moving when it gives the reading. In an adult, a fever is considered to be greater than 38 degrees C (100.4 degrees F). For children, a fever is 37.5 degrees C (99.5 degrees F).
Which of the following is an appropriate task for the nurse aide?
It is important for every health care professional to only perform tasks that are within the scope of practice. As a CNA, you are a valuable team member to contribute to a care plan conference. The other tasks are for the nurse.
In Long Term Care Facilities, which shift usually gets the residents ready for their appointments, X-rays, etc.?
Helping residents prepare or be transported to procedures will most often happen on the day shift (7 a.m. -3:30 p.m.). If there is a prep or an order for NPO, another shift may be involved, but the main responsibility is on the day shift.
To help prevent resident falls, the nurse aide should
A primary safety rule in fall prevention is to always return a bed in the lowest position. Residents should be able to touch the floor with their feet so they can stand easily. Bed wheels should be locked and side rails down.
Which symptoms best indicate an instance of urinary tract infection?
A urinary tract infection (UTI) can cause several important signs and symptoms. The patient may feel an urgent need to urinate, but when on the toilet, actually have a few dribbles of urine. There can be pain, burning, or stinging while trying to urinate. The urine may appear cloudy or even have streaks or spots of blood. Always report any of these to the nurse.
A common eye disorder with a cloudy condition of the lens that reduces eyesight is known as
A cataract happens when the lens of the eye becomes cloudy, causing blurry and poor vision. If untreated, blindness will result. Cataracts are the most common cause of blindness in the world.
What is a pulse oximeter used to measure?
A pulse oximeter is a device used to measure pulse, as well as the amount, or saturation, of oxygen in the blood. It provides a quick reading, without having to do a lab test. Normal O2 saturation levels are 94-99%. Patients with COPD and emphysema will have levels of 90% and higher. Record the level as "SpO2" which indicates that a peripheral reading was obtained. Always notify the nurse of an SpO2 of less than 90%.
A patient suffering from pneumonia might exhibit symptoms such as
The signs and symptoms of pneumonia can range from mild to severe. Besides the those listed, a patient may have shortness of breath, fever, sweating, and chills. The patient may have extreme fatigue and older patients may appear confused.
Considering the resident’s activity, which of the following sets of vital signs should be reported to the charge nurse immediately?
The normal respiration rate for an adult at rest is between 12 to 20 breaths per minute. A rate of under 12 or over 25 breaths per minute while resting is considered abnormal. A rate of 32 is extremely high and should be reported to the nurse immediately.
The nervous system changes as people get older. Which change is considered normal?
Changes in the brain and nervous system are normal parts of getting older. As nerve cells die, they are not replaced. They are also slower in transmitting messages, causing delays in response times. It is important to note that dementia is not a normal part of aging.
The nurse asks you to change the urine drainage bag for a patient with an indwelling catheter. If you aren't sure how to change it, what should you do?
Do not attempt to do a procedure or give a treatment if you're not certain how to do it or if you have not been trained. Tell the nurse. The nurse may show you how, supervise the procedure, or give you another task. Patient safety comes first, so ask for help if you need it.
Swollen ankles and legs may be signs of
When the heart becomes weak, or has a defect, it can't pump efficiently. Because blood can't move, it starts to pool in the feet, ankles, and lower legs. This swelling is called edema.
Which one of the following amounts is the proper way to record urinary output?
Medical and pharmacy measurements use the metric system. One ounce equals 30 cc or 30 ml. 16 ounces = 480 cc or ml.
What is an embolism?
An embolism is usually a blood clot that travels through the bloodstream and becomes stuck in an artery or vein. It blocks blood flow, leading to tissue damage and possibly death. Fat or air can also cause an embolism. An embolism is a medical emergency.
Which of the following is considered a normal age-related change?
The bladder is a muscle that changes with age. The muscle walls become stiffer, causing a decrease in the bladder capacity. There is also a loss of muscle strength, which can lead to leakage or inability to completely empty the bladder.
Objective data is any information that is fact. This means that the information is unbiased and multiple people should be able to interpret the information in the same way. All of the following are an example of objective data EXCEPT
Subjective data is based on an individual's interpretation of a situation. Pain level is a good example. Each person has a different pain threshold that cannot be accurately measured. Two people who have had the same surgery may report entirely different levels of pain on the Pain Scale. Subjective information is not judged, but recorded as the person states.
A patient is nearing death. What should the nurse aide focus on?
As death nears, a patient may seem to be sleeping or unconscious. They are often aware of the presence of others and are able to hear. Support the patient and speak in a kind manner. Use touch and keep them comfortable.
A slipknot is used when securing a restraint so that ________.
A slipknot is secure, but can be easily released in an emergency, using one hand. It is also called a half-bow or quick release knot.
A resident who is incontinent of urine has an increased risk of developing ________.
When skin becomes wet from incontinence, it becomes soft and more likely to be damaged. Friction between the skin and clothing or linens is increased, leading to skin tears and abrasions. The risk for infection is also greater when skin is not intact.
You are measuring Mrs. Clark’s resting pulse and it is 106 beats per minute, which is significantly higher than her normal pulse. You should
Report sudden changes in vital signs to the nurse. A higher pulse rate can indicate infection, dehydration, stress, anxiety, or a heart condition. It's wise to wait 10-15 minutes and recheck the pulse.
The normal heart rate/pulse rate for an adult human is 60-100 bpm. An elevated heart rate can be expected with
With severe or uncontrolled bleeding, the loss of blood means that less oxygen is available for the body. As a result, the heart beats faster to try and compensate. Well-trained athletes have a normal heart rate of 40-60 bpm, because their hearts are strong and fit.
Mr. Martin drank 6 ounces of coffee and 3 ounces of orange juice during breakfast. How many cubic centimeters did he drink?
9 oz. = 270 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.
Wrinkles in the bed linens can lead to problems for residents. Which is the most serious problem that they can cause?
When a resident must stay in bed, it is very important to prevent skin breakdown. Any pressure can lead to the development of a decubitus ulcer (also called a pressure ulcer, pressure sore, or bed sore). Even a wrinkle or ridge in the bed linen can harm a resident's fragile skin. Keep linens smooth, clean, and dry.
The term atrophy refers to an organ or tissue becoming
Atrophy occurs with underuse or disease of a part of the body, causing a loss of cells. When muscles are not used, they can waste away, resulting in poor strength or movement. In Alzheimer's disease, the brain atrophies, shrinking until all functions are lost.
A resident has diabetes. Which is a common sign of a low blood sugar?
Hypoglycemia, or low blood sugar, causes a diabetic to become shaky. Other signs and symptoms are sweating, chills, nausea, and a rapid heartbeat. The resident may act confused, irritable, or anxious. As a CNA, you should know which residents are diabetic and what to watch for. Notify the nurse immediately.
Which blood pressure reading would you report to the nurse?
Hypertension is diagnosed when a person has consistent blood pressure measurements of 140/90 or greater. Hypertension has no symptoms as it develops; it can be present for years without a person knowing it. If untreated, it can cause hart failure and stroke.
A resident has an indwelling urinary catheter. While making rounds, the nurse aide notices that there is no urine in the drainage bag. The nurse aide should first __________.
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.
The resident’s weight is obtained routinely as a way to check the resident’s __________.
Weight is a good indicator of a resident's nutrition and calorie intake. It should stay within a range of a few pounds. Residents who have heart failure may be weighed daily to see if they are retaining fluid. Report any sudden weight gain or loss to the nurse.
Which specialist is responsible for assisting residents to do everyday activities?
An occupational therapist helps patients who are disabled or who have been injured develop or regain the skills needed for daily activities. They may teach a resident who has had a stroke to get dressed or use special devices to assist with eating.
Which of the following methods is the CORRECT way to remove a dirty isolation gown?
To remove an isolation gown, untie the gown and hold it on the front and pull it away from your body. When it is away from your body, roll the gown into a ball, keeping your gloves and wrists inside the sleeves. Pull one hand out of a sleeve, causing the inside of the gown to face you. Pull the other hand out and hold the inside of the gown to discard it in the appropriate receptacle.
Supine position is
The supine (pronounced "soo-pine") position is when the patient is on their back. Hint: both "supine" and "sky" start with an S. "When supine, I look at the sky.").
A resident who has stress incontinence ________.
Stress incontinence occurs when sudden pressure on the abdomen from laughing, coughing, or sneezing causes the bladder to leak. Weak pelvic floor muscles or the muscle that controls the urinary sphincter cannot keep urine from leaking. It is the most common type of incontinence in women.
Which stage of a pressure sore or ulcer involves breakdown of the subcutaneous layer of the skin?
Stage III of a pressure sore or pressure ulcer involves loss of the full skin thickness. There can be necrosis (dead tissue) as well as damage to muscles, bones, or supporting tissue. Monitoring and reporting reddened areas of skin (Stage I) is important to prevent further skin damage.
The Foley bag must be kept lower than the patient’s bladder because
When a patent has an indwelling Foley catheter, the bag should be lower than the bladder to prevent backflow. 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.
If a patient does not have a bowel movement for more than ______, the patient is considered at an increased risk for developing constipation and the nurse should be notified.
While each person has an individual pattern of bowel movements, after three days, notify the nurse. Feces can become hard and difficult or painful to pass, especially after three days. Constipation is generally defined as fewer than three bowel movements a week.
Which of the following diet has no food restrictions?
A Regular diet has no restrictions regarding salt, sugar, or texture. A patient can have any food they wish. Low sodium diets have strict salt limits and diabetic diets restrict sugar and carbohydrates. A soft diet has foods that are easy to chew and swallow.
As the nurse aide begins their assignment, which should they do first?
When prioritizing, start with the resident who has the most urgent need. Helping the resident who has finished toileting is most important. The patient will be comfortable, and you can then do the other tasks.
The Heimlich maneuver (abdominal thrust) is administered to the patient if they have
A person who is choking will automatically grab their throat. This is a signal for help. Abdominal thrusts (the Heimlich maneuver) is the best response to choking. Calling for assistance as you prepare to do abdominal thrusts will alert others of the emergency. A quick back slap can be tried, but if the food does not immediately dislodge, the nurse aide must quickly move to start abdominal thrusts. Performing abdominal thrusts involves standing behind the client and using hands to exert upward pressure on the bottom of the diaphragm.
Which one of these conditions requires Contact Isolation precautions?
Contact isolation precautions are used when infection or disease can be spread by touching the patient or items in the patient's room that could possibly be contaminated. Scabies, MRSA, severe diarrhea, and RSV are examples of conditions requiring gowns and gloves to care for the patient.
The safety device used to transfer a weak or dependent patient from a bed to a chair is called a
A gait belt is used to assist in transferring patients from one position to another, such as from bed to a chair or wheelchair. It's also used to support patients that are weak or have balance problems when they ambulate.
What is the condition when patients are unable to control their bladder?
Urinary incontinence is the inability to hold or control urine. Normal aging or some conditions cause the sphincter, or valve, that controls urination, to become weak.
Of the symptoms below, which one is most associated with Rheumatoid Arthritis?
Rheumatoid Arthritis (RA) is an autoimmune disease. The patient's immune system attacks the lining of the membranes that surround the joints, causing severe pain, swelling, and redness. Over time, the joints become deformed. Women are more likely than men to develop RA.
When a new ambulatory patient is admitted, the nurse aide should always
When admitting a patient, after giving care, or when leaving the patient's room, always ensure that the patient's call signal is within reach. Patients must always have access to their care providers. For safety, bed should be in the lowest position.
Food moves more slowly through the digestive tract of older people. What is a common consequence?
Up to 50% of nursing home residents have constipation. Besides having a slower digestive process, older people often don't drink enough water or eat a balanced diet. Lack of activity can also contribute to constipation.
When admitting a new client, which of the following should a nurse aide observe and record?
As a CNA, you may be the first to observe any unusual or abnormal marks on a client's skin. Bruises, reddened areas, or dry patches are examples that you should note. Describe your observation accurately. Also tell the nurse.
What does the abbreviation BID stand for?
The term "BID" means twice a day. It is an abbreviation for Latin "bis in die." It is used in medicine and pharmacy, and can also be written as b.i.d. or bid.
What type of isolation precautions are necessary for a patient with a gastrointestinal infection?
Enteric precautions are used for infections such as C. difficile, rotavirus, or norovirus, as well as severe diarrhea of an unknown cause. Precautions for staff include proper hand washing and putting on gown and gloves before entering the patient's room. All linen is bagged in the patient's room. Visitors may not eat in the room and must wash their hands with soap and water when leaving the room.
A resident is on a bladder training program. The nurse aide can expect the resident to ______.
Bladder training is a good way to treat urinary incontinence. Residents are placed on a toileting schedule that gradually increases the time between emptying their bladder and the bladder capacity. Fluids are restricted in the evening to prevent incontinence during the night.
Charting is an accurate record of all medical care while in hospital, including therapies given, treatments performed, and the patient's progress. Information typically found in the chart includes all of the following EXCEPT
A medical chart is a permanent record of a patient's diagnoses, evaluations, treatments, and condition. Each health care team member records their treatment and the patient's response. Including visitor names would be highly unusual.