Clinical Procedures and Protocols Flashcards

When a resident in restraints calls for help and the call light is unanswered, the nurse aide who passes the room should:

Answer: Stop and respond to the resident immediately

Restrained residents are vulnerable and any response to distress must be immediate — all staff are responsible for responding to calls for help.

When transferring a resident from a wheelchair to a bed using a gait belt, where should the belt be placed?

Answer: Around the resident's waist over their clothing

The gait belt is applied snugly around the waist over clothing, with fingers fitting underneath, to provide safe gripping during transfers.

A resident with a fresh surgical wound is noted to have bright red blood saturating the dressing. The nurse aide should:

Answer: Apply pressure over the dressing and call for the nurse immediately

Active bleeding requires direct pressure to slow it while the nurse is urgently notified, as dressing changes require a nurse's assessment and order.

Which observation about a resident's stool should be reported to the nurse immediately?

Answer: Dark tarry stool (melena)

Dark, tarry (melena) stool indicates possible upper gastrointestinal bleeding and must be reported to the nurse immediately.

During a bed bath, the water temperature should be tested by the nurse aide using:

Answer: The inside of the wrist before applying to the resident

The inside of the wrist is sensitive to temperature and is used to test water before exposing the resident to avoid burns.

When a resident states they do not want a procedure performed, the nurse aide should:

Answer: Respect the refusal and immediately report it to the nurse

Residents have the right to refuse treatment; the nurse aide must respect this right and report the refusal to the nurse promptly.

When assisting a resident with a partial weight-bearing (PWB) status to ambulate, the nurse aide should ensure the resident:

Answer: Touches only their toes to the floor on the affected side

Partial weight-bearing means the resident touches their toes or rests limited weight on the affected side as directed — not full weight and not no weight.