INACE Clinical Procedures and Protocols 2 — Questions and Answers
Question 1: When performing passive range-of-motion exercises, the nurse aide should move each joint to the point of:
- Maximum stretch beyond resistance
- Slight resistance, then stop (Correct answer)
- Pain, then back off slightly
- A fixed count of 20 repetitions regardless of response
Correct answer: Slight resistance, then stop
Passive ROM should be performed until slight resistance is felt; pushing beyond resistance can cause injury.
Question 2: A resident's urinary catheter drainage bag should always be positioned:
- At the same level as the bladder
- Above the level of the bladder
- Below the level of the bladder (Correct answer)
- Clipped to the bedrail at mattress height
Correct answer: Below the level of the bladder
The drainage bag must remain below bladder level at all times to allow urine to drain by gravity and prevent backflow.
Question 3: Which action is correct when applying an elastic (ACE) bandage to a resident's lower leg?
- Wrap from the knee downward toward the foot
- Wrap from the foot upward toward the knee (Correct answer)
- Apply the bandage as tightly as possible for best support
- Wrap in a figure-eight pattern starting at the thigh
Correct answer: Wrap from the foot upward toward the knee
Elastic bandages are applied from distal to proximal (foot to knee) to promote venous return and prevent swelling.
Question 4: When a resident is using a mechanical lift for transfer, the sling should be:
- Removed immediately once the resident is seated
- Left in place under the resident at all times
- Removed when it is safe to do so per facility policy (Correct answer)
- Replaced with a new sling after every use
Correct answer: Removed when it is safe to do so per facility policy
Sling removal follows facility policy; some slings are designed to remain in place while others should be removed after transfer for comfort and skin integrity.
Question 5: The correct technique for inserting a rectal suppository includes:
- Positioning the resident supine and inserting 1 inch
- Positioning the resident in Sims' position and inserting past the internal sphincter (Correct answer)
- Inserting the suppository with gloved fingers as far as possible
- Applying the suppository to the anal opening only
Correct answer: Positioning the resident in Sims' position and inserting past the internal sphincter
The resident is placed in Sims' position, and the suppository is inserted past the internal sphincter (about 1–1.5 inches in adults) to be effective.
Question 6: When providing care to a resident with a colostomy, the nurse aide should empty the pouch when it is:
- Completely full and leaking
- One-third to one-half full (Correct answer)
- Changed at the same time every 24 hours
- Only when the resident requests it
Correct answer: One-third to one-half full
Emptying the pouch when one-third to one-half full prevents leakage and reduces the risk of skin breakdown around the stoma.
Question 7: A nurse aide notices a resident's IV site is swollen, cool, and pale. This most likely indicates:
- Phlebitis
- Infiltration (Correct answer)
- Septicemia
- Air embolism
Correct answer: Infiltration
Swelling, coolness, and pallor at an IV site indicate infiltration, where IV fluid has leaked into surrounding tissue.
INACE Clinical Procedures and Protocols 2
When performing passive range-of-motion exercises, the nurse aide should move each joint to the point of: