CNA State Exam MI

A resident often carries a doll with her, treating it like her baby. One day she is wandering around crying that she can't find her baby. The nurse aide should

(A) ask the resident where she last had the doll.

(B) ask the activity department if they have any other dolls.

(C) offer comfort to the resident and help her look for her baby.

(D) let the other staff know the resident is very confused and should be watched closely.

C

A nurse aide is asked to change a urinary drainage bag attached to an indwelling urinary catheter. The nurse aide has never done this before. The best response by the nurse aide is to

(A) change the indwelling catheter at the same time.

(B) ask another nurse aide to change the urinary drainage bag.

(C) change the bag asking for help only if the nurse aide has problems.

(D) ask a nurse to watch the nurse aide

change the bag since it is the first time.

D

Before feeding a resident, which of the

following is the best reason to wash the

resident's hands?

(A) The resident may still touch his/her mouth

or food.

(B) It reduces the risk of spreading airborne diseases.

(C) It improves resident morale and appetite.

(D) The resident needs to keep meal routines.

A

Which of the following is a job task performed by the nurse aide?

(A) Participating in resident care planning conferences

(B) Taking a telephone order from a physician

(C) Giving medications to assigned residents

(D) Changing sterile wound dressings

A

Which of the following statements is true about range of motion (ROM) exercises?

(A) Done just once a day

(B) Help prevent strokes and paralysis

(C) Require at least ten repetitions of each exercise

(D) Are often performed during ADLs such as bathing or dressing

D

While the nurse aide tries to dress a resident who is confused, the resident keeps trying to grab a hairbrush. The nurse aide should

(A) put the hairbrush away and out of sight.

(B) give the resident the hairbrush to hold.

(C) try to dress the resident more quickly.

(D) restrain the resident's hand.

B

A resident who is lying in bed suddenly

becomes short of breath. After calling for help, the nurse aide's next action should be to

(A) ask the resident to take deep breaths.

(B) take the resident's vital signs.

(C) raise the head of the bed.

(D) elevate the resident's feet.

C

A resident who has cancer is expected to die within the next couple of days. Nursing care for this resident should focus on

(A) helping the resident through the stages of grief.

(B) providing for the resident's comfort.

(C) keeping the resident's care routine, such as for bathing.

(D) giving the resident a lot of quiet time and privacy.

B

While giving a bedbath, the nurse aide hears the alarm from a nearby door suddenly go off. The nurse aide should

(A) wait a few minutes to see if the alarm stops.

(B) report the alarm to the charge nurse immediately.

(C) make the resident being bathed safe and go check the door right away.

(D) stop the bedbath and go check on the location of all assigned residents.

C

Gloves should be worn for which of the

following procedures?

(A) Emptying a urinary drainage bag

(B) Brushing a resident's hair

(C) Ambulating a resident

(D) Feeding a resident

A

When walking a resident, a gait or transfer belt is often

(A) worn around the nurse aide's waist for back support.

(B) used to keep the resident positioned properly in the wheelchair.

(C) used to help stand the resident, and then removed before walking.

(D) put around the resident's waist to provide a way to hold onto the resident.

D

Which of the following statements is true about residents who are restrained?

(A) They are at greater risk for developing pressure sores.

(B) They are at lower risk of developing

pneumonia.

(C) Their posture and alignment are improved.

(D) They are not at risk for falling.

A

A resident has diabetes. Which of the following is a common sign of a low blood sugar?

(A) Fever

(B) Shakiness

(C) Thirst

(D) Vomiting

B

When providing foot care to a resident it is important for the nurse aide to

(A) remove calluses and corns.

(B) check the feet for skin breakdown.

(C) keep the water cool to prevent burns.

(D) apply lotion, including between the toes.

B

When feeding a resident, frequent coughing can be a sign the resident is

(A) choking.

(B) getting full.

(C) needs to drink more fluids.

(D) having difficulty swallowing.

D

When a person is admitted to the nursing home, the nurse aide should expect that the resident will

(A) have problems related to incontinence.

(B) require a lot of assistance with personal care.

(C) experience a sense of loss related to the life change.

(D) adjust more quickly if admitted directly from the hospital.

C

A resident gets dressed and comes out of his room wearing shoes that are from two different pairs. The nurse aide should

(A) tease the resident by complimenting the resident's sense of style.

(B) ask if the resident realizes that the shoes do not match.

(C) remind the resident that the nurse aide can dress the resident.

(D) ask if the resident lost some of his shoes.

B

A resident's wife recently died. The resident is now staying in his room all the time and eating very little. The best response by the nurse aide is to

(A) remind the resident to be thankful for the years he shared with his wife.

(B) tell the resident that he needs to get out of his room at least once a day.

(C) understand the resident is grieving and give him chances to talk.

(D) avoid mentioning his wife when caring for him.

C

When a resident refuses a bedbath, the nurse aide should

(A) offer the resident a bribe.

(B) wait awhile and then ask the resident again.

(C) remind the resident that people who smell don't have friends.

(D) tell the resident that nursing home policy requires daily bathing.

B

When a resident is combative and trying to hit the nurse aide, it is important for the nurse aide to

(A) show the resident that the nurse aide is in control.

(B) call for help to make sure there are

witnesses.

(C) explain that if the resident is not calm a restraint may be applied.

(D) step back to protect self from harm while speaking in a calm manner.

D

During lunch in the dining room, a resident begins yelling and throws a spoon at the nurse aide. The best response by the nurse aide is to

(A) remain calm and ask what is upsetting the resident.

(B) begin removing all the other residents from the dining room.

(C) scold the resident and ask the resident to leave the dining room immediately.

(D) remove the resident's plate, fork, knife, and cup so there is nothing else to throw.

A

Which of the following questions asked to the resident is most likely to encourage conversation?

(A) Are you feeling tired today?

(B) Do you want to wear this outfit?

(C) What are your favorite foods?

(D) Is this water warm enough?

C

When trying to communicate with a resident who speaks a different language than the nurse aide, the nurse aide should

(A) use pictures and gestures.

(B) face the resident and speak softly when talking.

(C) repeat words often if the resident does not understand.

(D) assume when the resident nods his/her head that the message is understood.

A

While walking down the hall, a nurse aide looks into a resident's room and sees another nurse aide hitting a resident. The nurse aide is

expected to

(A) contact the state agency that inspects the nursing facility.

(B) enter the room immediately to provide for the resident's safety.

(C) wait to confront the nurse aide when he/she leaves the resident's room.

(D) check the resident for any signs of injury after the nurse aide leaves the room.

B

Before touching a resident who is crying to offer comfort, the nurse aide should consider

(A) the resident's recent vital signs.

(B) the resident's cultural background.

(C) whether the resident has been sad

recently.

(D) whether the resident has family that visits routinely.

B

When a resident is expressing anger, the nurse aide should

(A) correct the resident's misperceptions.

(B) ask the resident to speak in a kinder tone.

(C) listen closely to the resident's concerns.

(D) remind the resident that everyone gets angry.

C

When giving a backrub, the nurse aide should

(A) apply lotion to the back directly from the

bottle.

(B) keep the resident covered as much as

possible.

(C) leave extra lotion on the skin when

completing the procedure.

(D) expect the resident to lie on his/her

stomach.

B

A nurse aide finds a resident looking in the refrigerator at the nurses' station at 5 a.m. The resident, who is confused, explains he needs breakfast before he leaves for work. The best

response by the nurse aide is to

(A) help the resident back to his room and into bed.

(B) ask the resident about his job and if he is hungry.

(C) tell him that residents are not allowed in the nurses' station.

(D) remind him that he is retired from his job and in a nursing home.

B

Which of the following is true about caring for

a resident who wears a hearing aid?

(A) Apply hairspray after the hearing aid is in place.

(B) Remove the hearing aid before showering.

(C) Clean the earmold and battery case with water daily, drying completely.

(D) Replace batteries weekly.

B

Residents with Parkinson's disease often require assistance with walking because they

(A) become confused and forget how to take steps without help.

(B) have poor attention skills and do not notice safety problems.

(C) have visual problems that require special glasses.

(D) have a shuffling walk and tremors.

D

A resident who is inactive is at risk of

constipation. In addition to increased activity and exercise, which of the following actions helps to prevent constipation?

(A) Adequate fluid intake

(B) Regular mealtimes

(C) High protein diet

(D) Low fiber diet

A

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

(A) ask the resident to try urinating.

(B) offer the resident fluid to drink.

(C) check for kinks in the tubing.

(D) obtain a new urinary drainage bag.

C

A resident who is incontinent of urine has an increased risk of developing

(A) dementia.

(B) urinary tract infections.

(C) pressure sores.

(D) dehydration.

C

When cleansing the genital area during

perineal care, the nurse aide should

(A) cleanse the penis with a circular motion starting from the base and moving toward the tip.

(B) replace the foreskin when pushed back to cleanse an uncircumcised penis.

(C) cleanse the rectal area first, before

cleansing the genital area.

(D) use the same area on the washcloth for each washing and rinsing stroke for a female resident.

B

Which of the following is considered a normal age-related change?

(A) Dementia

(B) Contractures

(C) Bladder holding less urine

(D) Wheezing when breathing

C

A resident is on a bladder retraining program. The nurse aide can expect the resident to

(A) have a fluid intake restriction to prevent sudden urges to urinate.

(B) wear an incontinent brief in case of an accident.

(C) have an indwelling urinary catheter.

(D) have a schedule for toileting.

D

A resident who has stress incontinence

(A) will have an indwelling urinary catheter.

(B) should wear an incontinent brief at night.

(C) may leak urine when laughing or coughing.

(D) needs toileting every 1-2 hours throughout the day.

C

The doctor has told the resident that his cancer is growing and that he is dying. When the resident tells the nurse aide that there is a mistake, the nurse aide should

(A) understand that denial is a normal

reaction.

(B) remind the resident the doctor would not lie.

(C) suggest the resident ask for more tests.

(D) ask if the resident is afraid of dying.

A

A slipknot is used when securing a restraint so that

(A) the restraint cannot be removed by the resident.

(B) the restraint can be removed quickly when needed.

(C) body alignment is maintained while

wearing the restraint.

(D) it can be easily observed whether the restraint is applied correctly.

B

When using personal protective equipment (PPE) the nurse aide correctly follows Standard

Precautions when wearing

(A) double gloves when providing perineal care to a resident.

(B) a mask and gown while feeding a resident that coughs.

(C) gloves to remove a resident's bedpan.

(D) gloves while ambulating a resident.

C

To help prevent resident falls, the nurse aide should

(A) always raise siderails when any resident is in his/her bed.

(B) leave residents' beds at the lowest level when care is complete.

(C) encourage residents to wear larger-sized, loose-fitting clothing.

(D) remind residents who use call lights that they need to wait patiently for staff.

B

As the nurse aide begins his/her assignment, which of the following should the nurse aide do first?

(A) Collect linen supplies for the shift

(B) Check all the nurse aide's assigned

residents

(C) Assist a resident that has called for

assistance to get off the toilet

(D) Start bathing a resident that has physical therapy in one hour

C

Which of the following would affect a nurse aide's status on the state's nurse aide registry and also cause the nurse aide to be ineligible to work in a nursing home?

(A) Having been terminated from another facility for repeated tardiness

(B) Missing a mandatory infection control inservice training program

(C) Failing to show for work without calling to report the absence

(D) Having a finding for resident neglect

D

To help prevent the spread of germs between patients, nurse aides should

(A) wear gloves when touching residents.

(B) hold supplies and linens away from their uniforms.

(C) wash hands for at least two minutes after each resident contact.

(D) warn residents that holding hands spreads germs.

B

When a sink has hand-control faucets, the nurse aide should use

(A) a paper towel to turn the water on.

(B) a paper towel to turn the water off.

(C) an elbow, if possible, to turn the faucet controls on and off.

(D) bare hands to turn the faucet controls both on and off.

B

When moving a resident up in bed who is able to move with assistance, the nurse aide should

(A) position self with knees straight and bent at waist.

(B) use a gait or transfer belt to assist with the repositioning.

(C) pull the resident up holding onto one side of the drawsheet at a time.

(D) bend the resident's knees and ask the resident to push with his/her feet.

D

The resident's weight is obtained routinely as a way to check the resident's

(A) growth and development.

(B) adjustment to the facility.

(C) nutrition and health.

(D) activity level.

C

Which of the following is a right that is included in the Resident's Bill of Rights?

(A) To have staff available that speak different languages on each shift

(B) To have payment plan options that are based on financial need

(C) To have religious services offered at the facility daily

(D) To make decisions and participate in own care

D

Which of the following, if observed as a sudden change in the resident, is considered a possible warning sign of a stroke?

(A) Dementia

(B) Contractures

(C) Slurred speech

(D) Irregular heartbeat

C

Considering the resident's activity, which of the following sets of vital signs should be reported to the charge nurse immediately?

(A) Resting: 98.6°-98-32

(B) After eating: 97.0°-64-24

(C) After walking exercise: 98.2°-98-28

(D) While watching television: 98.8°-72-14

A

Handwashing: checklist for clinical skills

1 Begin handwashing by wetting hands and applying

soap to hands?

2 Use friction to distribute soap and create lather

cleansing front and back of hands, between fingers,

around cuticles, under nails, and wrists?

3 Provide cleansing friction for a minimum of 20 seconds with hands lathered with soap?

4 Rinse hands and wrists removing soap?

5 Use clean paper towel(s) to dry hands and wrists, and dispose of used paper towel in trash?

6 End handwashing skill with clean hands avoiding recontamination of hands before procedure completed (e.g., having direct contact with faucet handles or sink surfaces once hands washed)?

Indirect care: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Ask resident about preferences during care? (IC)

4 Use Standard Precautions and infection control

measures when providing care? (IC)

5 Ask resident about comfort or needs during care or

before care completed? (IC)

6 Promote resident's rights during care? (IC)

7 Promote resident's safety during care? (IC)

Ambulate the resident using a transfer/gait belt: checklist for clinical skills

1 Greet resident, address by name and introduce self?

(IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Apply transfer/gait belt before standing resident,

placing around the resident's waist and over

clothing, secure so that only flat fingers/hand fit

under belt, and the belt does not catch skin or skin

folds (e.g. breast tissue)?

4 Provide signal or cue to resident before assisting to

stand?

5 Assist resident to stand while holding onto the

transfer/gait belt without holding belt only at the

front or only at nearest side (if assisting to stand

from the side)?

6 Ask about how resident feels upon standing?

7 Walk resident while standing to the side and slightly

behind resident?

8 Provide support while walking resident with an arm

around resident's back holding transfer/gait belt?

9 Ask about how resident feels during ambulation?

10 Walk resident at least 10 steps?

11 Assist resident to turn and have back of legs

positioned against the seat of chair before resident

sits?

12 Provide support to sit resident back into chair?

13 Remove transfer/gait belt from resident's waist

without harming resident (e.g., pulling transfer/gait

belt) when seated in chair after ambulation?

14 Maintain own body mechanics when assisting

resident to stand and sit?

15 Leave resident positioned in chair in proper body

alignment and hips against back of seat?

16 Ask resident about preferences during care? (IC)

17 Use Standard Precautions and infection control measures when providing care? (IC)

18 Ask resident about comfort or needs during care or

before care completed? (IC)

19 Promote resident's rights during care? (IC)

20 Promote resident's safety during care? (IC)

Assist resident needing to use a bedpan: checklist for clinical skills

1 Greet resident, address by name and introduce self?

(IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Place protective pad on bed over bottom sheet,

under buttocks/upper thigh area, before placing

bedpan, and remove the pad after bedpan is

removed?

4 Place and remove bedpan by either having resident

positioned on side to turn on/off back, onto/off

bedpan, or having resident raise hips off bed?

5 Position bedpan under resident according to

form/shape of the selected bedpan?

6 Position bedpan to allow for collection?

7 Raise the head of the bed after positioning the

resident on the bedpan, and lower the head of the

bed before removing bedpan?

8 Ask resident to call when finished or if needs help,

leaving call light within the resident's reach before

leaving resident to use bedpan?

9 Leave toilet paper within resident's reach before

leaving resident to use bedpan?

10 Wear gloves when removing bedpan and while

emptying and cleaning bedpan?

11 Empty contents of bedpan into toilet, rinse bedpan

pouring contents into toilet, and dry bedpan?

12 Offer resident damp washcloth or paper towel, or

hand wipe, to cleanse hands after bedpan used,

before end of care?

13 Complete skill storing bedpan and toilet paper,

placing soiled linens in hamper, and disposing of

trash?

14 Keep resident positioned a safe distance from the

edge of the bed at all times?

15 Ask resident about preferences during care? (IC)

16 Use Standard Precautions and infection control

measures when providing care? (IC)

17 Ask resident about comfort or needs during care or

before care completed? (IC)

18 Promote resident's rights during care? (IC)

19 Promote resident's safety during care? (IC)

Change bed linen while the resident remains in bed: checklist for clinical skills

1 Greet resident, address by name and introduce self?

(IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Keep resident positioned a safe distance from the

edge of the bed at all times?

4 Remove and replace bottom sheet on one side of

the bed, before turning resident to remove and

replace sheet on the other side of the bed?

5 Keep resident positioned on a bottom sheet

throughout procedure?

6 Secure bottom sheet to mattress (e.g., for fitted

sheet secure over all four corners of the mattress;

for flat sheet, tuck at head of bed and on sides and

extend toward bottom of mattress so that resident's

heels are not against any exposed mattress)?

7 Leave bottom sheet free of creases or folds?

8 Turn or position resident to remove or replace

sheet(s) without pulling sheets in a manner that

creates friction and risks skin shearing?

9 Replace the top sheet over resident with a clean

sheet?

10 Tuck top sheet under foot of mattress leaving sheet

placed loosely, avoiding pressure against toes and

allowing for foot movement?

11 Leave top sheet placed on top of resident to cover

body up to shoulder level, without tucking in along

sides?

12 Keep pillow positioned under resident's head

throughout and at the end of the procedure, except

when removed briefly to replace pillowcase?

13 Complete procedure with resident positioned

between the top and bottom sheet?

14 Complete skill placing soiled linens in hamper and

disposing of trash?

15 Ask resident about preferences during care? (IC)

16 Use Standard Precautions and infection control

measures when providing care? (IC)

17 Ask resident about comfort or needs during care or

before care completed? (IC)

18 Promote resident's rights during care? (IC)

19 Promote resident's safety during care? (IC)

Change resident's position to a

supported side-lying position: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Assist resident with turning onto side before placing

positioning devices?

4 Keep resident positioned a safe distance from the

edge of the bed at all times?

5 Use positioning device/padding or pillow under or

against resident's back that maintains side-lying

position?

6 Leave resident positioned on side with upper knee

bent in front of the lower leg?

7 Support resident's top leg by placing device(s)/

padding or pillow(s) between legs?

8 Position device(s)/padding or pillow(s) placed

between legs so that bony prominences of the

knees and ankles are separated?

9 Leave the resident positioned on side without lying

on the shoulder, arm, and hand?

10 Leave pillow placed under head positioned to also

support the resident's neck and chin?

11 Place device/padding or pillow positioned to support

the resident's upper arm, supporting both the

shoulder and arm?

12 Ask resident about preferences during care? (IC)

13 Use Standard Precautions and infection control

measures when providing care? (IC)

14 Ask resident about comfort or needs during care or

before care completed? (IC)

15 Promote resident's rights during care? (IC)

16 Promote resident's safety during care? (IC)

Dress a resident who has a weak arm: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Include resident in decision-making about clothing

to wear?

4 Collect all garments before removing hospital gown?

5 Support affected arm while undressing and

dressing?

6 Remove hospital gown?

7 Dress affected arm first?

8 Gather up sleeve to ease pulling over affected arm?

9 Dress resident by putting on pants, shirt with

sleeves, and socks?

10 Move resident's extremities gently without overextension

or force when undressing and dressing?

11 Apply clothing correctly (e.g. front of shirt in front),

adjust clothing for comfort, neatness, alignment,

and close fasteners?

12 Place dirty gown in hamper?

13 Keep resident positioned a safe distance from the

edge of the bed at all times?

14 Ask resident about preferences during care? (IC)

15 Use Standard Precautions and infection control

measures when providing care? (IC)

16 Ask resident about comfort or needs during care or

before care completed? (IC)

17 Promote resident's rights during care? (IC)

18 Promote resident's safety during care? (IC)

Empty contents of resident's urinary drainage bag, and measure and record urine output on an Intake and Output (I&O) form: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care

before beginning and during care? (IC)

3 Wear gloves while handling the urinary drainage

bag, graduate, or any urine-filled container, and

remove gloves before documenting I&O?

4 Set graduate or bedpan on barrier placed on

floor and empty full contents of drainage bag into

the graduate or bedpan?

5 Empty contents of urinary drainage bag without

contaminating drainage tube (e.g., touching

container) and close and protect drain (e.g.,

clamp and tuck drain into pocket) after emptying

drainage bag?

6 Set graduate on flat surface protected with

barrier to read, obtaining measurement by

reading graduate at eye level, and if urine

poured into graduate from a bedpan, complete

task over toilet pouring the full amount of urine

into the graduate?

7 Empty urine in graduate into toilet after

measuring, rinse and dry container, pouring rinse

water into toilet?

8 Record output with clean hands?

9 Record output within +/- 50 mL/cc's of nurse's

measurement?

10 Record output as urine and indicate the correct

time on the I&O form?

11 Leave bag hanging from bed frame (not side

rail), and drainage bag and tubing off (not

touching) the floor?

12 Keep urinary drainage bag positioned lower than

bladder throughout care?

13 Complete skill having stored equipment, placing

soiled linens in hamper, and disposing of trash?

14 Ask resident about preferences during care? (IC)

15 Use Standard Precautions and infection control

measures when providing care? (IC)

16 Ask resident about comfort or needs during care

or before care completed? (IC)

17 Promote resident's rights during care? (IC)

18 Promote resident's safety during care? (IC)

Feed a resident who is sitting in a chair: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Assist or cue resident to sit upright in chair before

feeding?

4 Offer or assist resident to wash hands before

feeding using a damp washcloth, paper towel, or

hand wipe?

5 Sit while feeding the resident?

6 Offer to protect resident's clothing with a barrier

before feeding, and if used, remove barrier at end

of feeding?

7 Use spoon to feed?

8 Offer fluids to drink throughout feeding; at least

every 2-3 bites of food?

9 Allow resident the opportunity to swallow before

feeding the next bite?

10 Converse with resident during meal

(e.g., encourage intake)?

11 Leave area around resident's mouth clean and dry

when care completed?

12 Complete skill placing any used linen in hamper,

disposing of trash, and leaving overbed table dry?

13 Record the amount of the resident's food intake on

the Food and Fluid Intake Form within 25% of the

nurse's measurement?

14 Record the amount of the resident's fluid intake on

the Food and Fluid Intake Form within 25% of the

nurse's measurement?

15 Ask resident about preferences during care? (IC)

16 Use Standard Precautions and infection control

measures when providing care? (IC)

17 Ask resident about comfort or needs during care or

before care completed? (IC)

18 Promote resident's rights during care? (IC)

19 Promote resident's safety during care? (IC)

Measure and record a resident's radial pulse: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Support resident's arm in manner to avoid dangling

while pulse is taken?

4 Use fingers (not thumb) to take pulse?

5 Places fingers on wrist at radial pulse to measure

pulse rate?

6 Count pulse for one full minute?

7 Record resident's pulse rate on Measurement Form

within +/- 4 beats per minute of nurse's

measurement?

8 Ask resident about preferences during care? (IC)

9 Use Standard Precautions and infection control

measures when providing care? (IC)

10 Ask resident about comfort or needs during care or

before care completed? (IC)

11 Promote resident's rights during care? (IC)

12 Promote resident's safety during care? (IC)

Measure and record a resident's respirations: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Measure rate of respirations without providing

instructions to resident about how to breathe?

4 Count respirations for one full minute?

5 Record resident's respiration rate on Measurement

Form within +/- 2 breaths per minute of nurse's

measurement?

6 Ask resident about preferences during care? (IC)

7 Use Standard Precautions and infection control

measures when providing care? (IC)

8 Ask resident about comfort or needs during care or

before care completed? (IC)

9 Promote resident's rights during care? (IC)

10 Promote resident's safety during care? (IC)

Provide catheter care to a female resident who has an indwelling urinary catheter: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before

beginning and during care? (IC)

3 Wear gloves while providing catheter care, cleaning

equipment, and handling soiled underpads,

washcloths, and towels?

4 Position towel or underpad under buttocks/thigh

area before cleansing, and when care completed

remove towel or underpad, or leave resident on a

dry underpad?

5 Use water of safe temperature for washing and

rinsing?

6 Use soapy washcloth to clean inside labia?

7 Change spot on soapy washcloth for each washing

stroke, wiping from front to back when cleansing

inside labia?

8 Cleanse catheter using clean area of washcloth,

washing away from body and down the catheter at

least 3-4 inches?

9 Use clean soap-free wet washcloth to remove soap?

10 Change spot on washcloth for each rinsing stroke,

wiping front to back inside labia, and away from

body when rinsing catheter?

11 Dry perineal area, from front to back after

completing cleansing and rinsing?

12 Leave tubing free of kinks or obstructions, and keep

tubing and urinary drainage bag off floor?

13 Keep urinary drainage bag positioned lower than

bladder throughout procedure?

14 Complete skill having rinsed, dried and stored

basin, placing soiled linens in hamper, disposing of

trash, and leaving overbed table dry?

15 Keep resident positioned a safe distance from the

edge of the bed at all times?

16 Ask resident about preferences during care? (IC)

17 Use Standard Precautions and infection control

measures when providing care? (IC)

18 Ask resident about comfort or needs during care or

before care completed? (IC)

19 Promote resident's rights during care? (IC)

20 Promote resident's safety during care? (IC)

Provide foot care to a resident who is

sitting in a chair: checklist for clinical skills

1 Greet resident, address by name and introduce self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Place water filled basin on protective barrier on floor to prepare for foot care?

4 Use water of safe temperature for soaking foot?

5 Soak resident's foot in basin of water?

6 Use soapy washcloth to wash foot without adding soap directly to basin of water?

7 Wash top and bottom of foot and between toes?

8 Remove soap from foot including between toes?

9 Dry entire top and bottom of foot including between toes?

10 Warm lotion before applying to foot (e.g., warming in hands, placing bottle in warm water)?

11 Apply lotion to top and bottom of foot, excluding between toes?

12 Remove visible excess lotion from foot if present after applying?

13 Apply sock to foot leaving sock smooth, and replace shoe; leaving any fasteners, such as ties, secured?

14 Provide support to lower extremity throughout

procedure as needed to avoid strain?

15 Avoid placing resident's barefoot directly on floor before, during or after foot care?

16 Complete skill having rinsed, dried and stored

basin, placing soiled linens in hamper, and

disposing of trash?

17 Ask resident about preferences during care? (IC)

18 Use Standard Precautions and infection control

measures when providing care? (IC)

19 Ask resident about comfort or needs during care or before care completed? (IC)

20 Promote resident's rights during care? (IC)

21 Promote resident's safety during care? (IC)

Provide mouth care to a resident

who has a denture: checklist for clinical skills

1 Greet resident, address by name and introduce self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Wear gloves when handling denture, providing

mouth care, and rinsing equipment?

4 Protect denture from damage while cleaning by

lining sink, filling sink with water, or holding

denture directly over basin?

5 Protect denture from contamination (e.g., use a

barrier when setting denture on surfaces, avoid

placing or rinsing denture in sink water)?

6 Use cool or tepid running water to clean and rinse denture?

7 Brush all surfaces of the denture using a toothbrush or denture brush with toothpaste?

8 Rinse denture to remove toothpaste?

9 Handle clean denture maintaining cleanliness after brushed, placing denture in denture cup filled with clean cool or tepid water?

10 Leave denture cup on resident's bedside cabinet or overbed table unless following resident's preference about where denture cup should be stored?

11 Protect resident's clothing before providing mouth care and remove protective cover when care is completed?

12 Provide mouth care cleaning upper and lower gums, using moistened foam-tipped applicator or

toothbrush with toothpaste?

13 Offer resident cup of water to rinse mouth after

mouth care?

14 Provide emesis basin or disposable cup to resident to use for spitting as needed?

15 Leave area around resident's mouth clean and dry when care is completed?

16 Complete skill having rinsed, dried and stored basin (if used), emptying sink of water and removing barrier from sink (if used), placing soiled linens in hamper, disposing of trash, and leaving overbed table dry?

17 Ask resident about preferences during care? (IC)

18 Use Standard Precautions and infection control

measures when providing care? (IC)

19 Ask resident about comfort or needs during care or before care completed? (IC)

20 Promote resident's rights during care? (IC)

21 Promote resident's safety during care? (IC)

Provide mouth care to a resident who has teeth: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Assist resident to sitting position in bed by raising

HOB and using pillows as needed to position

resident upright at 60° to 90° before offering fluid

or brushing teeth?

4 Protect resident's clothing before providing mouth care and remove protective cover when care completed?

5 Moisten toothbrush with water and apply toothpaste before brushing teeth?

6 Wear gloves when brushing resident's teeth and

wear throughout mouth care including when rinsing basin and toothbrush?

7 Brush sides and biting surfaces of teeth and the

gum line with a gentle motion?

8 Offer resident cup of water to rinse mouth after

brushing?

9 Provide resident an emesis basin or disposable cup to use for spitting as needed, such as after rinsing mouth?

10 Leave area around resident's mouth clean and dry when care completed?

11 Complete skill having rinsed, dried and stored

basin, placing soiled linens in hamper, disposing of

trash, and leaving overbed table dry?

12 Ask resident about preferences during care? (IC)

13 Use Standard Precautions and infection control

measures when providing care? (IC)

14 Ask resident about comfort or needs during care or before care completed? (IC)

15 Promote resident's rights during care? (IC)

16 Promote resident's safety during care? (IC)

Provide perineal care to a female resident

who is incontinent of urine: checklist for clinical skills

1 Greet resident, address by name and introduce self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Wear gloves while providing perineal care, cleaning equipment, and handling soiled underpads, washcloths and towels?

4 Remove soiled underpad and replace with dry

underpad before beginning cleansing?

5 Use water of safe temperature for washing and

rinsing?

6 Use soapy washcloth to wash front perineum to

include genital and skin fold areas of groin?

7 Change spot on washcloth for washing and rinsing strokes when cleansing inside the vulva?

8 Wipe from front to back with all washing and rinsing strokes when cleansing the front perineum, to include the genital and skin fold areas of groin?

9 Use clean, soap-free, wet washcloth to remove soap from resident's skin on front perineum?

10 Dry front perineum after washed and rinsed, using towel to pat dry, moving from front to back?

11 Replace water in basin during care if it becomes

cold or soapy?

12 Position resident on side to prepare for cleansing of buttocks and rectal area?

13 Wash, rinse, and dry buttocks and rectal area?

14 Wipe from front to back with all washing and rinsing strokes when cleansing the rectal area?

15 Leave resident on dry underpad at completion of procedure?

16 Complete skill having rinsed, dried and stored

basin, placing soiled linens in hamper, disposing of

trash, and leaving overbed table dry?

17 Keep resident positioned a safe distance from the edge of the bed at all times?

18 Ask resident about preferences during care? (IC)

19 Use Standard Precautions and infection control

measures when providing care? (IC)

20 Ask resident about comfort or needs during care or before care completed? (IC)

21 Promote resident's rights during care? (IC)

22 Promote resident's safety during care? (IC)

Provide resident hand and nail care: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Use water of safe temperature for soaking fingers or hand?

4 Place fingers or full hand into basin of water to soak before removing residue from under nails?

5 Clean hand surfaces using wet washcloth, cleaning between fingers, and if soap used, rinse or remove soap using a clean, soap-free, wet washcloth?

6 Use flat edge of orangewood stick to remove

residue under tips of each fingernail, and remove

residue from edge of orangewood stick, if present,

before using again to clean under another

fingernail?

7 Rest resident's hand on barrier such as a dry towel once removed from basin while providing nail and hand care?

8 Dry hand before completing care?

9 Leave nails smooth (e.g., free of jagged edges)?

10 Apply lotion to cleaned hand after nail care

finished?

11 Support resident's arm if raised off table when

providing nail and hand care?

12 Remove visible excess lotion from hand if present at completion of hand care?

13 Complete skill having rinsed, dried and stored

basin, placing soiled linens in hamper, disposing of

trash, disposing of or storing emery board and

orangewood stick, and leaving overbed table dry?

14 Ask resident about preferences during care? (IC)

15 Use Standard Precautions and infection control

measures when providing care? (IC)

16 Ask resident about comfort or needs during care or before care completed? (IC)

17 Promote resident's rights during care? (IC)

18 Promote resident's safety during care? (IC)

Provide resident a partial bed bath and back rub: checklist for clinical skills

1 Greet resident, address by name and introduce self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Use water of safe temperature for washing and

rinsing?

4 Cleanse eyes by using soap-free washcloth wiping eye from the inside corner to the outside corner, changing to clean area of washcloth before returning to inner corner and before cleansing the other eye?

5 Wash resident's face using a soap-free wet

washcloth, unless ascertains resident's preference

to use soap before washing face?

6 Leave face dry after washing?

7 Contain corners of washcloth while washing and

rinsing (e.g., forming mitt)?

8 Protect bed linen from becoming wet during

washing and rinsing of body (non-face)?

9 Wash resident's body (non-face) using a wet

washcloth with small amount of soap?

10 Use clean, soap-free, wet washcloth to remove soap from resident's skin?

11 Wash and rinse resident's neck, hand, arm, chest,

and abdomen?

12 Dry neck, hand, arm, chest, and abdomen?

13 Support arm if raised off bed to wash, rinse, and

dry the back side of arm?

14 Assist resident to turn onto side before cleansing back?

15 Wash, rinse, and dry back?

16 Replace basin of water during task if it becomes

cold or soapy?

17 Warm lotion before applying to resident's back

(e.g., warming in hands, placing bottle in warm

water)?

18 Use lotion to provide back rub with long gliding and circular motions?

19 Place clean hospital gown on resident and secure gown in back?

20 Complete skill having rinsed, dried and stored

basin, placing soiled linens in hamper, disposing of

trash, and leaving overbed table dry?

21 Keep resident positioned a safe distance from the edge of the bed at all times?

22 Ask resident about preferences during care? (IC)

23 Use Standard Precautions and infection control

measures when providing care? (IC)

24 Ask resident about comfort or needs during care or before care completed? (IC)

25 Promote resident's rights during care? (IC)

26 Promote resident's safety during care? (IC)

Provide resident with passive range of motion

(ROM) exercises to one elbow and wrist: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Exercise only correct joints and only correct

side when performing range of motion (ROM)?

4 Support extremity to protect the working joint

throughout ROM exercises?

5 Bend and straighten arm at elbow through ROM

(flexion/extension)?

6 Move wrist through ROM by bending wrist to move hand down and back (flexion and hyperextension)?

7 Ask resident to report discomfort during ROM or ask if resident has discomfort during ROM exercises?

8 Control extremity throughout ROM exercises

providing smooth, slow, non-forceful movement?

9 Ask resident about preferences during care? (IC)

10 Use Standard Precautions and infection control

measures when providing care? (IC)

11 Ask resident about comfort or needs during care or before care completed? (IC)

12 Promote resident's rights during care? (IC)

13 Promote resident's safety during care? (IC)

Provide resident with passive range of motion

(ROM) exercises to one shoulder: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Exercise only correct joints and only correct

side when performing range of motion (ROM)?

4 Support extremity to protect the working joint

throughout ROM exercises?

5 Move shoulder through ROM, raising and lowering arm alongside, toward head of bed (HOB) and back to mattress (flexion/extension)?

6 Move resident's shoulder through ROM taking arm away from side and back to side (abduction/

adduction)?

7 Ask resident to report discomfort during ROM or

ask if resident has discomfort during ROM

exercises?

8 Control extremity throughout ROM exercises

providing smooth, slow, non-forceful movement?

9 Ask resident about preferences during care? (IC)

10 Use Standard Precautions and infection control

measures when providing care? (IC)

11 Ask resident about comfort or needs during care or before care completed? (IC)

12 Promote resident's rights during care? (IC)

13 Promote resident's safety during care? (IC)

Provide resident with passive range of motion

(ROM) exercises to one hip, knee and ankle: checklist for clinical skills

1 Greet resident, address by name, and introduce

self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Exercise only correct joints and only correct

side when performing range of motion (ROM)?

4 Support extremity to protect the working joint

throughout ROM exercises?

5 Move resident's hip and knee through ROM, flexing knee and hip, raising toward torso and returning back to mattress (flexion/extension)?

6 Support extremity to prevent heel friction against

mattress during ROM exercises?

7 Move resident's foot up toward head and point

down toward the mattress through ROM

(dorsiflexion/plantar flexion)?

8 Ask resident to report discomfort during ROM or

ask if resident has discomfort during ROM

exercises?

9 Control extremity throughout ROM exercises

providing smooth, slow, non-forceful movement?

10 Ask resident about preferences during care? (IC)

11 Use Standard Precautions and infection control

measures when providing care? (IC)

12 Ask resident about comfort or needs during care or before care completed? (IC)

13 Promote resident's rights during care? (IC)

14 Promote resident's safety during care? (IC)

Transfer the resident from the bed into a

wheelchair using a pivot technique and a

transfer/gait belt: checklist for clinical skills

1 Greet resident, address by name and introduce self? (IC)

2 Provide explanations to resident about care before beginning and during care? (IC)

3 Place wheelchair near resident's bed before

assisting resident to sit at edge of bed?

4 Move wheelchair footrests out of the way before

standing resident for transfer (e.g., lift, swing, or

remove)?

5 Place nonskid footwear (e.g., shoes) on resident

before standing resident for transfer?

6 Provide support to assist resident to sitting position on side of bed, without pulling resident by lower arms or hands?

7 Provide resident opportunity to sit on side of bed to adjust to change in position before beginning transfer?

8 Position resident's feet flat on the floor before

standing to begin transfer?

9 Prepare for transfer by positioning wheelchair with front interior wheel close enough to bed so that transfer can be completed as a pivot?

10 Lock wheelchair before standing resident to begin transfer?

11 Apply transfer/gait belt before standing resident,

placing around the resident's waist and over

clothing, secured so that only flat fingers/hand fit

under belt, and the belt does not catch skin or skin

folds (e.g. breast tissue)?

12 Provide cue or signal to resident before assisting to stand?

13 Stand in front of resident reaching under resident's arms to hold transfer/gait belt at sides or around back throughout transfer?

14 Brace one or both of resident's legs during transfer while assisting to stand, turn, and sit?

15 Maintain own body mechanics when assisting

resident to stand, turn, and sit?

16 Transfer resident as a pivot completed without

having resident take step(s) to reach wheelchair,

and before assisting resident to sit in wheelchair,

positions with the back of resident's legs against

the seat of wheelchair?

17 Support resident to provide for controlled gentle lowering into seat of wheelchair?

18 Leave resident positioned in wheelchair in proper body alignment, hips against back of seat, and feet on footrests?

19 Remove transfer/gait belt from resident's waist

without harming resident (e.g., pulling transfer/gait

belt) when transfer is complete?

20 Ask resident about preferences during care? (IC)

21 Use Standard Precautions and infection control

measures when providing care? (IC)

22 Ask resident about comfort or needs during care or before care completed? (IC)

23 Promote resident's rights during care? (IC)

24 Promote resident's safety during care? (IC)