INACE Patient Care and Safety 3 — Questions and Answers
Question 1: When measuring a resident's blood pressure, the cuff should be placed:
- Directly over thick clothing for convenience
- About 1 inch above the antecubital space (Correct answer)
- Below the wrist on the forearm
- Loosely around the upper arm with two fingers gap
Correct answer: About 1 inch above the antecubital space
The lower edge of the blood pressure cuff should sit approximately 1 inch (2–3 cm) above the antecubital fossa for accurate readings.
Question 2: A nursing assistant is caring for a resident with a urinary catheter. Which action increases the risk of a catheter-associated urinary tract infection (CAUTI)?
- Keeping the drainage bag below the level of the bladder
- Securing the catheter tubing to the resident's thigh
- Allowing the drainage bag to rest on the floor (Correct answer)
- Emptying the drainage bag when it is two-thirds full
Correct answer: Allowing the drainage bag to rest on the floor
Placing the drainage bag on the floor allows bacteria to travel up the tubing into the bladder, significantly increasing CAUTI risk.
Question 3: A confused resident tries to climb out of bed at night. The most appropriate nursing assistant action is to:
- Apply wrist restraints to keep the resident in bed
- Lower the bed to its lowest position and place the call light within reach (Correct answer)
- Tell the resident firmly to stay in bed
- Raise all side rails to their highest position
Correct answer: Lower the bed to its lowest position and place the call light within reach
Lowering the bed and ensuring call-light access are safe, non-restraint interventions that reduce fall injury risk.
Question 4: Which vital sign finding should the nursing assistant report to the nurse immediately?
- Oral temperature of 98.6°F (37°C)
- Radial pulse of 72 beats per minute
- Respiratory rate of 26 breaths per minute (Correct answer)
- Blood pressure of 118/76 mmHg
Correct answer: Respiratory rate of 26 breaths per minute
A respiratory rate of 26 breaths per minute is above the normal adult range of 12–20 and indicates potential respiratory distress.
Question 5: A resident's advance directive states 'Do Not Resuscitate' (DNR). The nursing assistant finds the resident unresponsive and not breathing. The correct action is to:
- Begin CPR while another staff member checks the chart
- Call for the nurse immediately without beginning CPR (Correct answer)
- Wait 5 minutes before notifying the nurse
- Begin CPR because the nursing assistant's duty overrides the DNR
Correct answer: Call for the nurse immediately without beginning CPR
A valid DNR order means CPR should not be initiated; the nursing assistant must notify the nurse immediately and follow the documented care plan.
Question 6: The purpose of using a draw sheet (lift sheet) when moving a resident up in bed is to:
- Restrain the resident during repositioning
- Reduce friction and shear forces on the resident's skin (Correct answer)
- Replace the need for a second caregiver
- Keep the resident warm during the move
Correct answer: Reduce friction and shear forces on the resident's skin
A draw sheet allows caregivers to slide the resident smoothly, reducing friction and shear that can damage fragile skin.
Question 7: When providing oral care to an unconscious resident, the nursing assistant should position the resident:
- Flat on their back (supine)
- On their side with the head slightly lowered (lateral Sims' position) (Correct answer)
- Sitting upright at 90 degrees
- Prone with the head turned to one side
Correct answer: On their side with the head slightly lowered (lateral Sims' position)
Lateral positioning with the head slightly lowered prevents aspiration of fluids into the airway during oral care.
INACE Patient Care and Safety 3
When measuring a resident's blood pressure, the cuff should be placed: