INACE Clinical Procedures and Protocols 3 — Questions and Answers
Question 1: When performing mouth care on an unconscious resident, the nurse aide should position the resident:
- Flat on their back with head tilted back
- On their side with head turned to the side (Correct answer)
- In a high Fowler's position
- In a prone position
Correct answer: On their side with head turned to the side
Positioning an unconscious resident on their side with the head turned prevents aspiration of fluids during oral care.
Question 2: After removing gloves, the nurse aide must:
- Apply hand sanitizer only if hands look dirty
- Wash hands with soap and water or use hand sanitizer (Correct answer)
- Immediately put on a new pair of gloves
- Wipe hands with a paper towel only
Correct answer: Wash hands with soap and water or use hand sanitizer
Hand hygiene must be performed after glove removal because gloves can have microscopic holes and hands may be contaminated during removal.
Question 3: A resident on a thickened-liquid diet who is coughing and choking during meals most likely has:
- Food allergies
- Dysphagia (Correct answer)
- Gastroesophageal reflux disease
- Denture problems
Correct answer: Dysphagia
Coughing and choking during meals are classic signs of dysphagia (difficulty swallowing), which is why thickened liquids are prescribed.
Question 4: Which statement about applying a dry sterile dressing is correct?
- The nurse aide can apply sterile dressings to any wound independently
- The nurse aide should touch only the outer edges of sterile dressings (Correct answer)
- Sterile technique is not required for dry dressings
- The nurse aide should always re-wet dry dressings before applying
Correct answer: The nurse aide should touch only the outer edges of sterile dressings
When handling sterile dressings, only the outer edges should be touched to maintain sterility of the surface that contacts the wound.
Question 5: What is the purpose of a draw sheet (pull sheet) during repositioning?
- To restrain the resident during movement
- To reduce friction and shear on the resident's skin (Correct answer)
- To measure the resident's weight during transfer
- To prevent the resident from rolling out of bed
Correct answer: To reduce friction and shear on the resident's skin
A draw sheet reduces friction and shear forces on the skin during repositioning, decreasing the risk of pressure injury development.
Question 6: When measuring a resident's output from a urinary drainage bag, the nurse aide should:
- Estimate the amount visually without measuring
- Pour urine into a graduate at eye level to read the measurement (Correct answer)
- Record the amount in tablespoons for accuracy
- Measure only once per shift regardless of amount
Correct answer: Pour urine into a graduate at eye level to read the measurement
Urine must be poured into a graduate (measuring container) and read at eye level to ensure an accurate measurement.
Question 7: A resident receiving tube feedings should be kept in which position during and after the feeding?
- Flat to promote gravity feeding
- 30 to 45 degrees elevation of the head (Correct answer)
- Trendelenburg position
- Right lateral decubitus position only
Correct answer: 30 to 45 degrees elevation of the head
Elevating the head of the bed 30–45 degrees during and for at least 30 minutes after tube feeding reduces the risk of aspiration.
INACE Clinical Procedures and Protocols 3
When performing mouth care on an unconscious resident, the nurse aide should position the resident: