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
How should the eyes be washed during a bed bath?
- From the inner corner outward, with plain water
- From the outer corner inward, with plain water
- From the inner corner outward, with soapy water
- Back and forth across the lid, with soapy water
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A. From the inner corner outward, with plain water
Wiping from the inner corner (near the nose) outward moves drainage away from the tear duct, and a clean part of the washcloth is used for each eye. Soap is not used because it irritates the eyes.
Reference: Personal care: bathing
A nurse who is very busy hands a nursing assistant a resident's pill and says, 'Just give this to her for me.' What should the nursing assistant do?
- Give the pill, because the nurse remains responsible for it
- Decline, explaining that aides do not give medication
- Give the pill only if the resident confirms it is hers
- Leave the pill at the bedside for the resident to take later
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B. Decline, explaining that aides do not give medication
Giving medications is outside the nursing assistant's scope of practice unless the aide holds a separate medication aide certification. A nurse cannot delegate a task the aide is not allowed to do, so being told to do it does not make it acceptable.
Reference: Role of the nursing assistant: scope of practice