The nursing assistant suspects that a patient in the facility is being abused because of various unexplained bruises, refusal to answer most questions, and refusal of ADLs. Which of the following actions should the nursing assistant do next?

What is important for a nursing assistant to do when she is helping her patient with a partial bath?

Keep the bath curtain closed in order to provide the patient with privacy.

For any procedure that you conduct, one of the most important actions that you need to provide to your patient is privacy. Lukewarm water will not keep the patient warm enough, using a towel to cover your patient will not provide them with enough privacy and the patient’s feet are always washed last.

A patient with an ileostomy evacuates feces through the

ileum

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

Which of the following is not the nurse aid's responsibility for fire prevention measures?

Taking cigarettes and matches away from all patients and visitors

The nurse aide may not take away clients and visitors cigarettes or matches while smoking by them may not be appropriate. However, the nurse aide can certainly mark these actions to the charge nurse. The nurse aide should also be familiar with policies regarding smoking or smoking areas, to inform smokers if there are designated places. All staff must be aware of fire extinguisher locations and what to do in the event of a fire. Notifying the nurse or maintenance department of any damaged electrical wiring or sockets, as well as faulty electrical equipment can prevent a fire.

Mrs. Shumway has an order for I&O. You have picked up her breakfast and note she drank half of a 6oz. glass of juice, 4oz. of milk, and 8oz. of coffee, how much should you document?

450cc

The question is about HALF of a 6oz. glass. 15 oz. = 450 cc. When converting ounces (oz.) to cubic centimeters (cc) remember that 1 oz. = 30 cc. Although an ounce is slightly more, the amounts are considered to be equal by doctors and pharmacists. Also, 1 cc = 1 ml.

What should the nurse aide put on the client’s feet when they are going to help the client walk from the bed to a chair?

Rubber soled slippers or shoes

What do signs and symptoms of shock probably include?

Low blood pressure, tachycardia, clammy, and pale skin

Signs of shock involve low blood pressure (hypotension), a rapid heart rate (tachycardia), a weak pulse, and pale skin which can be damp or clammy. The customer may also be breathing rapidly (hyperventilation). The customer may also be confused or not alert. Shock is an emergency situation, requiring rapid treatment.

Out of the four following statements, which one is correct about Alzheimer's patients?

It is important for a patient with Alzheimer’s to maintain a routine to avoid confusion and overstimulation.

It is absolutely imperative that an Alzheimer's patient maintain a routine. And a decrease in appetite and hallucinations are often common. It is important to frequently re-orient the patient.

All of the following options are signs of impending death, except ___________.

The patient’s appetite has increased.

Impending death will more likely cause a decrease in appetite rather than an increase. The other options are all common signs of a human body shutting down.

Where should the nurse aide’s fingertips be placed on the client’s when taking a client’s radial pulse?

Wrist

A radial pulse is found at the client’s wrist. To locate it, place your index and middle fingers on the hollow area below the thumb. Light pressure are applied to feel the pulse. Count each beat for 30 seconds and multiply by 2 to get the pulse rate. If the client has an irregular heartbeat, count for 60 seconds. Record the pulse rate in the client’s chart.

Why are indwelling catheters secured or taped to a patient’s leg?

So that any kind of trauma to the patient can be prevented.

If the catheter is secured to the patient’s leg, this could prevent any kind of trauma to the patient, should the catheter accidentally be pulled. A catheter is already fixed in the patient’s bladder with a balloon, so it cannot easily be dislodged. If the catheter is secured to the patient’s leg, any kind of trauma to the patient could be prevented, should the catheter accidentally be pulled.

Of the following procedures, which one should be used for washing the perineum of a patient who has a catheter to minimize the spread of bacteria or further infection and contamination.

Wash the patient from the meatus out.

Washing from the meatus out is the correct washing practice as it avoids further spreading of contamination. Peroxide is not a cleanser so should not be used to wash a patient. The other two options are cleaning in the opposite direction that they should be in.

The nursing assistant suspects that a patient in the facility is being abused because of various unexplained bruises, refusal to answer most questions, and refusal of ADLs. Which of the following actions should the nursing assistant do next?

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