CNA Test Four

Afrebrile

without fever

Aneroid manometer

that part of the sphygmomanometer (BP cuff) that includes the dial that indicates the systolic and diastolic pressures during blood pressure checks

Apical pulse

pulse point over heart

arteries

Blood vessels that carry blood AWAY from the heart

brachial pulse

pulse point in crook of elbow

bradycardia

pulse rate less than 60 bpm

bradypnea

A respiratory rate less than 12 breaths/min

carotid pulse

pulse point on neck

cheyne-stokes

alternating periods of slow, irregular breathing and rapid, shallow breathing, plus short periods of absent breathing(prob followed by death)

diastole

resting phase of the heart, bottom reading on blood pressure reading(diastolic)

dyspnea

painful or difficult breathing

eupnea

normal breathing

hypertension

High blood pressure, higher than 140/90

hypotension

low blood pressure persistently lower than 90/60 mm Hg

millimeters of mercury

mmHg- for blood pressure

orthostatic hypotension

low blood pressure that occurs upon standing up

pedal pulse

pulse on foot, used to check circulation of the leg

radial pulse

the pulse felt at the wrist

sphygmomanometer

blood pressure cuff

systole

working phase of heart when heart is pumping blood to the body(systolic reading, top number)

tachycardia

pulse rate more than 100 bpm

tachypnea

respiratory rate more than 20 breaths per minute

temporal pulse

pulse point in the temples of the head

veins

Blood vessels that carry blood back to the heart

cubic centimeter(cc) is equal to______

milliliter

edema

fluid intake>fluid output, tissues swell with water

Vital signs show_____

how well vital organs are functioning(pulse, temperature, respiration, and blood pressure)

Importance of VS

-changes can indicate resident's condition worsening
-can reflect response to medication/treatment
-value of a vital sign may be basis for a medication

What is the 5th vital sign

pain(subjective, whatever the resident says it is)

1 respiration=

1 inspiration and 1 expiration

regular breaths:

12-20 p/m, quiet, both sides of chests equal

regular pulse rate:

60-100 bpm

what can suddenly affect blood pressure?

activity/lifestyle choices
reaction to stress
acute injury or emergency
medications

what generally affects blood pressure?

age
gender
race

elevated blood pressure:

120-129(s) AND below 80(d)

hypertension

(S)130+ mmHg OR (D)80+ mmHg

hypotension

Never take a blood pressure on an arm that has:

IV, paralyzed, injured, mastectomy, burned, fractured, AV shunt

orthostatic hypotension process

1. BP checked while lying down, record
2. have resident sit up, wait 2 mins, check BP, and record
3. have resident stand up, wait 2 mins, check BP, and record
4. report to nurse/record
EXTRA: throughout process, check to see if resident is faint, dizzy, weak, or seeing spots

Preventing orthostatic hypotension

- per care plan, increase activity in stages
- before standing, dangle and have resident cough/deep breath and move legs in circles for 1-5 minutes
- ask resident to report weakness dizziness, faintness, and seeing spots
- may need 2 people

factors affecting temperature

- age
- exercise
- environment
- stress
- illness
- time of day

temperature sites

mouth, rectum, armpit(axilla), ear(tympanic), temporal

When NOT to take an oral temperature

Is unconscious
Recent facial or mouth surgery
Recent injury to face
Has sores, redness, or mouth pain
Is confused or agitated
History or seizure
Is using oxygen
Is mouth-breather
Has a feeding tube
Has diarrhea
Has rectal problem
Has heart disease
Recent rectal surgery
Is confused or agitated

Oral temperature

baseline- 98.6
normal range- 97.6-99.6

Rectal temperature

baseline- 99.6
normal range- 98.6-100.6

Axillary temperature

baseline- 97.6
normal range- 96.6-98.6

tympanic membrane temperature

baseline- 98.6
normal range- 97.6-99.6

temporal temperature

baseline- 98.6
normal range- 97.6-99.6

green/blue tipped nonmercury liquid filled glass thermometer is for what part of the body

oral

red tipped nonmercury liquid filled glass thermometer is for what part of the body

rectal

how much water intake does an adult need for survival/daily life

at least 1500 mL but normally 2000-2500mL

Edema may occur because of what diseases

heart or kidney

Nurse aide's role for someone with edema:

- obtain accurate weights per order
- increase pillows per resident's request
- restrict fluids per doctor's order
- measure and record I&O accurately, if ordered
- observe for and report signs/symptoms

dehydration

fluid intake is less than fluid output, may occur from vomiting/diarrhea/fever/or refusal to drink fluids(nurse aide, if ordered can force fluids)

importance of measuring I&O

- evaluates fluid balance
- evaluates kidney function
- planning and evaluating medical treatment
- carrying out special fluid orders
- helps prevent or detect complications from fluid intake
- fluid intake is a factor that reflects nutritional status

fluids considered as intake

- liquids that a resident eats+semi-liquid fluids that the resident eats+other fluids including IV and tube
-(liquids)water, milk, coffee, tea, juices, soups, soft drinks
-(semi-liquid) milkshakes, ice cream, sherbet, custard, pudding, gelatin, popsicles

typical serving sizes of liquids:
-water
-tea
-juice
-milk
-coffee
-soft drink
-gelatin
-soup

-water= 240mL
-tea= 180mL
-juice= 120mL
-milk= 240mL
-coffee= 240mL
-soft drink= 360mL
-gelatin= 120mL
-soup= 180mL

1 ounce is equal to how many mL

30

importance of determining intake of meals accurately

- Determining intake of meals accurately is important in identifying
the resident at risk for or already experiencing impaired nutrition
- Food intake is one of the factors that reflects the resident's
nutritional status
- Poor food intake at meals or changes in food intake that persists
for multiple meals may indicate an underlying problem or illness
and should be reported to the nurse
- Much of a resident's daily fluid intake comes from meals; when
resident has decreased appetite, can result in fluid/electrolyte imbalance.

Weights - Consistent Process

Weigh the resident:
• Wearing a similar type of clothing
• At approximately the same time of the day (preferably before breakfast)
• Using the same scale
• Either consistently wearing or not wearing orthotics or prostheses

importance of accurate weights

- Weight is one of the parameters that reflects the resident's nutritional status
- Fluid loss or retention can cause short term weight changes; abrupt weight changes along with change in food intake are signs of fluid and electrolyte imbalance.
- Weight loss may be important indicator of a change in resident's health status or sign of malnourishment
- If significant weight loss noted, health care team reviews for possible causes

A bed bath is given to:
A. increase comfort level of patient
b. promote good hygiene
c. all of the above

c

when giving a bath, begin with:
a. hair care
b. eyes and face
c. mouth care

b

If the nurse aide leaves the patient soiled, the NA could be charged with

neglect and abuse

The NA needs to roll the patient. What safety precaution should be taken 1st?
a. raise the side rail on the side to which the patient will be turned
b. call for assistance
c. use a turn sheet

a

the bed is raised to working height. What safety precaution must be taken when the bath is complete?
a. pour out bath water
b. dispose of linen
c. lower the bed
d. document bath given

c

what would you do 1st if your patient says no when asked if he wants a bath?
a. Tell the patient they don't have a choice
b. Tell the patient's nurse
c. Change your approach when asking about a bath

c

clothing must be changed when

wet or soiled

If you use one resident's clothing for another, it is called _______________ of the resident's property.

misappropriation(theft)

When a patient has a weak right arm, how do you assist the patient with dressing and undressing?
a. TOSS
b. POWS
c. Put your hand through the shirt to support the hand/arm that is weak
d. All of the above

d

POWS stands for

put on weak side

TOSS stands for

take off strong side

what must always be used with pericare?

gloves(and 2 towels OR 3 washcloths

Prior to performing pericare, the water temperature should be:
a. 105 degrees
b. Warm
c. The temperature the resident desires which is determined by having the resident check the water temp

a(NO MORE THAN 105, but the resident can let you know about personal preference- colder than 105)

When providing pericare , it is important to:
a. Move quickly to avoid embarrassment of the patient
b. Clean with a different area of the washcloth with each stroke
c. Wash only the genital area

b

You are going to bathe a resident in the next room. Can unused linen from the room you are currently in be used next door? YES NO explain your answer

no, because it is still considered infectious/dirty since it's from another patient's room

what would you do if you notice that your patient's toenails need trimming?

notify the nurse

your patient has an injury to his foot. This would be a __________ for infeciton

point/portal of entry

The diabetic often has decreased circulation and sensation (called peripheral neuropathy) that increases their risk for

infection/injury

residents have the right to ________ foot care, but they also have the right to _______ feet

refuse;clean

You are providing foot care. What abnormalities should you report?
a. Warm, pink feet
b. Reddened heels
c. Breaks in the skin
d. B and C

d

Never cut nails of a _________ patient.

diabetic

When providing oral care for the unconscious resident, the patient should be placed in which position?
a. Supine
b. Sims
c. Lateral
d. Prone

c

Water temperature for denture care is:
a. 105 degrees
b. Cold
c. Tepid

c

_______ helps rub off germs

friction

hand rubs can be used if hands are not visibly soiled T F

true

Areas most often missed with hand washing include:
a. Fingertips
b. Between fingers
c. Palms
d. Thumbs
e. All of the above

e

When you put on PPE, it protects you and the patient by breaking the ______________ link in the chain of infection.

mode of transmission

When should gloves and gown be removed when care is complete?
a. Before leaving the room at the doorway
b. Once outside of the patient room
c. When at the nurses' station

a

Your patient is on respiratory precautions and you are wearing a mask, in addition to gloves and gown. When is the mask removed?
a. First, then gloves and gown
b. After removal of gloves
c. Last as you leave the patient room, just inside the doorway

c

You are providing care to a resident on contact precautions. You need extra linen which is right outside the door. What should you do?
a. Dash out to get the linen and hope no one sees you
b. Remove gown and gloves prior to leaving the room and re-gown and glove before re-entering the room
c. Hang the gown on the door knob and re-use it after getting the linen

b

The nurse aide is taking vital signs, but is unsure of the BP reading. The appropriate action for the NA would be to:
a. Guess the BP
b. Write down values similar to previous readings
c. Re-take the BP and report to the nurse if there is continued difficulty

c

The NA obtains vital signs and determines that the pulse rate is lower than the normal range. The NA should:
a. Complete all unit vital signs, then report to the nurse
b. Report findings to the oncoming NA
c. Immediately report findings to the patient's nurse

c

When assisting the ambulatory patient to weigh, the NA should ensure patient safety by:
a. Having patient wear shoes or non-skid footwear
b. Using a gait belt
c. Ask for assistance

a

what are the 5 rights to specimen collection?

Right resident
Right specimen
Right container
Right date/time
Right storage/delivery

A fracture pan is used for a resident who has:
a. Pneumonia
b. A fractured ankle
c. A fractured pelvis
d. A head injury

c

When placing the patient on the bedpan, the HOB must be:
a. Semi-fowlers position
b. Flat
c. Elevated 75-90 degrees

c

After placing the patient on the bedpan, the HOB is raised:
a. Before removing gloves
b. After removing gloves
c. After removing gloves and washing hands

b

Prior to taking the resident off the bedpan, the NA must:
a. Put on gloves
b. Lower the HOB
c. Pull the bed linen to the foot of the bed
d. A & B only

d

incontinence is a normal part of aging? true/false

false