Which adult vital sign should be reported to the nurse right away?
- Respirations of 16 breaths per minute
- Oral temperature of 98.4 degrees F
- Blood pressure of 118/76 mm Hg
- Pulse of 124 beats per minute at rest
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D. Pulse of 124 beats per minute at rest
A resting pulse of 124 is well above the normal adult range of 60 to 100. The respirations, temperature and blood pressure listed are all within normal adult ranges.
Reference: Basic nursing skills: vital signs; reporting abnormal readings
A resident in a shared room needs perineal care. How does the nursing assistant protect the resident's privacy?
- Ask the roommate to look the other way
- Work quickly with the door left open
- Turn up the television to cover the sound
- Close the door and pull the curtain
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D. Close the door and pull the curtain
Closing the door and curtain, and uncovering only the part of the body being washed, protects privacy and dignity. Relying on a roommate to look away does not.
Reference: Resident rights (42 CFR 483.10): privacy during care
A resident with dementia says, 'I have to go home now. My children are waiting for their supper.' Her children are grown. What is the best response?
- Ask her about her children, then guide her to an activity
- Explain that her children are adults and she lives here now
- Tell her the children called and will come to collect her soon
- Remind her firmly that she asks the same thing every day
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A. Ask her about her children, then guide her to an activity
Arguing with facts the person cannot hold on to causes distress. Responding to the feeling behind the words and then redirecting is calming and honest. Saying the children are coming is a lie that leads to more upset when nobody arrives.
Reference: Dementia care: validation and redirection