NURSE 420 EXAM 2 LEADERSHIP.| VERIFIED SOLUTION
1. A client states: “ I do not want to be awakened for breakfast-I didn’t sleep at all last night.” What is the first action for the RN to take?
a. Notify the client’s provider
b. Talk with the client to work out a mutual plan
c. Consult w...
INACE, CNA Practice Exam 4, CNA practice
test 2, CNA Practice Test 1, Complete Verified
Solution
Reporting & Recording
-Check current documentation of resident status & care.
-Observe & report resident data (verbal).
-Record objective & subjective resident data (written)
Communicate need for changes in care plan.
- Report unsafe conditions.
-Place & receive phone calls
Objective Data
Things you can see, hear, feel, smell, or measure: Vital signs, weight, open sore on
arm, reddened area on hip, swollen knee, wheezing, skin cold clammy, foul smelling
urine, etc.
-Subjective Data
Things a resident tells you that cannot be observed through senses: Complaints of pain
(headache, chest pain, stomach ache), nausea, numbness & tingling of fingers, no
appetite, etc
At the Nurse's Station:
1 st ring. • Identify unit, give name & title. • Take message. • Do NOT give confidential
information. Refer caller to nurse
The Resident's Personal Phone:
Assist resident to answer. • Answer w/ consent. • If resident is unavailable, answer
bedside phone (not cell phone) & take a message; do NOT provide any confidential
info. Do NOT give your name or title, the name of the unit or facility
Answer call signal:
Used to signal for help.
- Bed, bathroom.
- Keep w/in reach.
-Strong side.
-Instruct on use.
-Remind to use when help needed.
- Answer promptly - Everyone responsible! Adaptations if limited mobility.
4. Reinforce instructions from other health professionals to resident & family
- Not responsible for teaching but for knowing & reinforcing/assisting resident
Inventory & label personal property
Upon admission, as acquired.
Instruct resident in use of body mechanics.
Keep body in good alignment; have good posture. Have a wide base of support (feet
shoulder-width apart).
-Use strongest & largest muscles (shoulders, upper arms, hips, thighs).
- Keep objects close to body.
- Avoid unnecessary bending & reaching.
,- Bend knees & squat. Don't bend your back!
-Get help from co-worker.
-Use proper equipment.
- Position feet & body in direction you are moving
-Avoid sudden & jerky movements. Count 1-2-3.
- Turn whole body when changing direction. Pivot, do NOT twist your back!
Calculate, report, & record
Food intake (solids): 0%, 25%, 50%, 75%, 100%
Fluid intake:
All oral fluids.
-Foods that melt at room temp.
- IV fluids & tube feedings.
- CNA only responsible for fluids by mouth.
Fluid output:
Urine, vomit, diarrhea - CNA only responsible.
- Wound drainage, hemorrhage - Nurse responsible.
Intake & Output
Intake: 1 oz = 30 ml
Output: urinals, graduates, bedpans, specimen containers
each line on urine container increases by 25 mL
Communicate w/ limited English proficient resident.
Utilize tools provided by facility
Assist w/ unit discharge procedure
Collect belongings, compare w/ personal belongings list.
- Assist w/ packing.
-Transport as indicated.
-Wish well.
- Return to room; strip bed, straighten, remove wastes & linens. If any additional
equipment, take to soiled utility room
Measure & Record VS & Weight
All VS:
Lying or sitting.
-At rest for 10-20 min.
-Obtain all VS of a resident (TPR & BP) before reporting any abnormal to nurse.
Temperature:
98.6 + 1⁰ (97.6⁰ - 99.6⁰ )
Elderly on lower end of range ≈ 97.6⁰
- Do not eat, drink, smoke for 15 min
Pulse
60 - 100 beats/min.
- Tachycardia > 100
- Bradycardia < 60
-Count for 30 sec & multiply by 2. If irregular, must count for full min
Respirations
12-20/min
Do not let know you are counting.
, Dyspnea
= difficulty breathing
Blood pressure
90/60 - 120/80
Systolic - top #
- Diastolic - bottom #
- Hypertension - high BP
Wait 1 min before retaking BP
Weight
SAME Scale
- SAME Time of Day (does NOT matter when!)
SAME Amount of Clothing (do NOT need to remove)
Routine urine specimen
anytime, earliest possible time
24-hour urine specimen
Keep chilled.
-Start w/ empty bladder.
-Start over if urine missed or stool/tissue present
Clean-catch urine specimen
Testing for UTI.
-Special cleansing wipes needed, sterile container. -
Start to urinate, stop, start again & collect.
Sputum specimen
Secretions from respiratory system.
-May rinse w/ clear water.
-Take 2-3 deep breaths, cough, expel.
stool specimen
Collect about 2 tbsp. Include anything unusual.
Collect specimens
Assist in preparation of specimen for transfer to laboratory
- Follow Standard Precautions!
- Place in clear biohazard specimen bag.
- Take to appropriate location according to facility policy:
- Specimen refrigerator, lab, etc.
standard percautions
Apply to care of ALL residents.
- Presume EVERYONE is INFECTED!
Presume ALL may contain germs:
Body fluids (blood, urine, saliva, wound drainage, vomit, etc.)
Body substances (stool)
Open skin
Mucous membranes (mouth, eyes, nose, perineum)
standard precautions guidelines
Wash your hands!
#1 in preventing spread of infection.
Using FRICTION most important aspect of handwashing.
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