Basic Nursing Skills pt.2

Which of the following is the safest way to confirm a resident’s identity? 

• Ask the resident’s roommate.

• Check the ID bracelet or tag attached to the resident.

• Call the resident by name and see if the person answers. 

• Look at the door number and compare it to your room list.

A resident with an ileostomy evacuates feces through the 

• jejunum.

• colon.

• anus.

• ileum.

Answer explanation

The ileum is the lowest part of the small intestine. An ileostomy is an opening in the abdomen that is created during surgery. The end of the ileum is placed outside the body and connected to a bag that collects the waste of the intestine. The ileostomy is usually on the lower right side of the body. 

To help ensure adequate circulation to prevent patient skin breakdown, you should 

• perform active or passive range-of-motion exercises.

• give back massages.

• change the patient’s position frequently.

• all of the above.

Meal trays have arrived. Before serving each tray, the nurse aide should 

• check each armband, even on familiar patients. 

• check the temperature of the food.

• ask patients if they are hungry.

• ask about dietary restrictions.

Answer explanation

Some clients have special diets, severe food allergies, or strict fluid restrictions. Before serving a meal tray, always check the client's ID band or tag and match it to the correct tray. Although it can be tempting to skip this step in a long-term care facility, the nurse aide is legally responsible for verifying the identity of each client before serving food or giving care. 

Mrs. Shumway's nursing care plan lists CHF (Congestive Heart Failure) as her primary dx. (diagnosis). You would expect her ADL routine to include which of the following? 

• Daily jog around the facility for one hour

• Daily am weight measurement

• Placement of TED hose after ambulation 

• Encouraging oral fluids

Answer explanation

Congestive heart failure is a chronic disease that occurs when the heart becomes weak and is no longer able to pump efficiently. It is important to monitor the client's weight. A sudden weight gain means that the client is retaining fluid. This puts a strain on the heart and lungs. The nurse aide should weigh the client every morning at the same time and record the weight. Notify the nurse of any sudden change. 

The circulatory system consists of the 

• blood vessels, lymph nodes, and spleen.

• blood vessels, arteries, veins, and capillaries.

• heart, aorta, pulmonary vessels, and lungs. 

• heart, arteries, veins, and capillaries.

Which of the following should be reported immediately? 

• a pulse of 90.

• a blood pressure of 90/40.

• temperature of 99.4°F.

• respirations of 12.

Which of the following measurements that you obtained from Mrs. Shumway should be reported immediately to the charge nurse? 

• Respiration 20

• B/P: 190/114

• Temperature 99°F

• Pulse 74

A nurse aide notices blood in a patient’s IV tubing. The aide should 

• notify the IV nurse.

• do nothing; that’s normal.

• stop the IV.

• try to flush the tubing.

Which of the following are associated with smoking? 

• heart attacks.

• vitamin c deficiency.

• pneumonia.

• all the above.