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With an air/water mattress, the aide SHOULD:
Detailed Rationale
Punctures destroy mattress integrityΓ’β¬βno pins, scissors, or needles.
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Client refuses unfamiliar foods. The aide SHOULD:
Detailed Rationale
Preference assessment allows meal substitution and prevents malnutrition.
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Common side effect in cancer treatment is:
Detailed Rationale
Pain, fatigue, mucositis are frequent cancer-therapy sequelae.
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When caring for an Alzheimer client, the aide SHOULD:
Detailed Rationale
Simple, consistent cues reduce cognitive load and anxiety.
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If a client becomes physically aggressive, the aide SHOULD:
Detailed Rationale
Personal safety first; de-escalate and alert nurse for further intervention.
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With oxygen therapy, which safety measure is correct?
Detailed Rationale
Oxygen supports combustionΓ’β¬βno-open-flame policy is mandatory.
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Client refuses BP check. The aide SHOULD:
Detailed Rationale
Report refusal at once; nurse assesses reason and clinical impact while respecting autonomy.
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Which symptom must be reported IMMEDIATELY?
Detailed Rationale
Cyanotic lips indicate hypoxemiaΓ’β¬βa medical emergency.
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Before starting a back-rub, the MOST important observation is:
Detailed Rationale
Open areas, bruises, or rashes contraindicate massage and require nursing evaluation.
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Sign of loss of independence to report is:
Detailed Rationale
Helplessness signals depression or decreased functionΓ’β¬βnurse can initiate support.
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While ambulating, client trips and begins to fall. The aide SHOULD:
Detailed Rationale
Controlled descent minimizes injury to both client and aide.
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Team member who provides MOST physical care is:
Detailed Rationale
Nurse aides deliver 80-90 % of direct hygiene, mobility, and feeding care.
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Another name for pressure sore is:
Detailed Rationale
Decubitus ulcer is the historical term; now called pressure injury.
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When lifting from floor, the aide SHOULD:
Detailed Rationale
Squat-lift (bend knees) uses leg muscles, protects back.
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To help constipation, the aide should encourage:
Detailed Rationale
Hydration plus fiber softens stool; enemas require nurse order.
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A dying client with no visitors should be:
Detailed Rationale
Presence and companionship relieve terminal loneliness.
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When dressing a client, FIRST:
Detailed Rationale
Assess motor limitations to sequence dressing (dress affected side first) and promote safety.
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Edema in ankles and feet should prompt the aide to:
Detailed Rationale
Edema may signal cardiac, renal, or venous issuesΓ’β¬βnurse determines intervention.
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The nurse aide is feeding a client while the client's head is tilted back. The client is at risk for:
Detailed Rationale
Tilting the head back during feeding compromises the airway's natural protective mechanisms, increasing the likelihood that food or liquid will enter the trachea instead of the esophagus, leading to aspiration, which may cause choking or aspiration pneumonia. Edema refers to fluid retention and swelling, unrelated to head position during feeding. Dyspnea is difficulty breathing, which may result from aspiration but is not directly caused by head tilt. Dysphasia refers to difficulty speaking, not swallowing; the correct term for swallowing difficulty is dysphagia, but head tilt exacerbates aspiration risk rather than causing dysphagia.
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The role of the nurse aide in restorative care is to:
Detailed Rationale
Restorative care focuses on helping clients regain or maintain their highest level of function and independence. Encouraging clients through setbacks supports motivation, builds confidence, and promotes long-term progress. Combining steps may overwhelm the client, notifying them of slow progress can be discouraging, and completing tasks for them undermines autonomy and hinders rehabilitation.
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A low-fat diet is ordered for a client. Which of the following foods is restricted?
Detailed Rationale
Butter, a high-fat dairy product with saturated fat, is typically restricted on a low-fat diet. Fish, particularly fatty fish like salmon, may contain healthy fats and is often allowed in moderation. Bread is generally low in fat unless prepared with added fats. Sugar is a carbohydrate, not a fat, and is not inherently restricted on a low-fat diet, though it may be limited for other reasons like diabetes.
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A client refuses to take a bath. What is the nurse aide's BEST response?
Detailed Rationale
Offering choice and flexibility respects the clientβs autonomy and promotes cooperation, reducing resistance by allowing the client to feel in control. Saying "I know best" dismisses their feelings, forcing compliance with "no way out" is coercive, and comparing them to others is invalidating and may provoke defensiveness.
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The unlawful restriction of a client's freedom of movement is called:
Detailed Rationale
False imprisonment is the intentional and unlawful confinement or restraint of a person against their will, directly applying to restricting a clientβs movement without justification. Defamation involves harming reputation through false statements, negligence is failure to provide reasonable care, and invasion of privacy relates to unauthorized intrusion, not physical restraint.
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To promote a client's rest, the nurse aide SHOULD:
Detailed Rationale
Reducing environmental noise creates a calm atmosphere conducive to rest and sleep. Keeping lights on disrupts circadian rhythms, asking questions engages the client mentally, and positioning upright may be needed for specific conditions but is not universally rest-promoting. Noise reduction is the most effective intervention.
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When providing care for a client after the client is pronounced dead, the nurse aide SHOULD:
Detailed Rationale
Honoring the clientβs spiritual and religious preferences after death is fundamental to respectful, person-centered end-of-life care, reflecting their wishes in rituals or handling. Delaying care until family arrives may not be feasible, side-lying is not standard unless specified, and removing tubes requires authorization and is secondary to respecting religious practices.
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Two nurse aides enter the room of a dying client to provide care. The nurse aides SHOULD:
Detailed Rationale
Explaining actions to a dying client, who may still be aware, promotes dignity, reduces anxiety, and honors person-centered care. Whispering may create secrecy, discussing the condition violates privacy, and silence may leave the client feeling ignored. Gentle communication is key.
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Incontinence may be defined as:
Detailed Rationale
Incontinence refers to the involuntary loss of bladder or bowel control, most commonly urinary incontinence. Redness of the skin may result from moisture exposure but is not the definition. Shortness of breath and leg cramps are unrelated to elimination control.
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Client rights are based on:
Detailed Rationale
Client rights are grounded in constitutional law, guaranteeing privacy, dignity, and freedom from abuse. Nursing home policies and Medicaid regulations derive from this framework, and doctorβs orders guide care but do not establish rights. Constitutional principles ensure universal rights.
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After anti-embolism stockings are applied, the stockings SHOULD:
Detailed Rationale
Anti-embolism stockings must be free of creases to ensure even compression, promoting venous return and preventing skin breakdown or thrombus formation. They are not worn for 24 hours continuously without skin checks, must fit snugly, and are for legs, not arms.
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The nurse aide may refuse to complete a task when:
Detailed Rationale
Refusing a task due to unfamiliarity with equipment protects client safety, as proceeding without training could cause harm. Refusing due to shift change or dislike is unprofessional, and a charge nurseβs presence supports task completion, not refusal.
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The nurse aide begins cardiopulmonary resuscitation (CPR) after witnessing a client collapse in the hallway. What is the BEST way to ensure an open airway during CPR?
Detailed Rationale
The head tilt-chin lift maneuver opens the airway by lifting the tongue from the throat, essential for effective CPR in an unresponsive adult without spinal injury. Abdominal thrusts are for choking, sternum pushing is for compressions, and giving a breath without an open airway may be ineffective.
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Which of the following actions can the nurse aide take to relieve a client's pain?
Detailed Rationale
Proper body alignment reduces strain on muscles and joints, alleviating discomfort within the nurse aideβs scope. Offering medication is outside their scope, long walks may worsen pain, and bright lights may increase discomfort. Positioning is a safe, effective intervention.
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The nurse aide is assigned to provide hair care to a client. Which of the following statements is TRUE regarding client hair care?
Detailed Rationale
Physical health influences hair condition through factors like malnutrition or illness. Nurse aides can wash hair, head coverings are not mandatory, and hair appearance impacts self-esteem. The link between health and hair is universally true.
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A client's dignity and respect are maintained by referring to the client by:
Detailed Rationale
Using the clientβs preferred name honors their identity and autonomy. Room numbers depersonalize, terms of endearment can be patronizing, and last names may feel impersonal unless requested. Following the clientβs preference upholds dignity.
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Which of the following could be a symptom of a urinary tract infection?
Detailed Rationale
Frequent voiding, often with urgency or burning, is a classic UTI symptom due to bladder irritation. Loose stools, leg cramps, and chest pain are unrelated to urinary tract issues. Frequent voiding directly correlates with UTI presentation.
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The nurse aide maintains a professional relationship with a client by:
Detailed Rationale
Reporting client condition changes to the nurse ensures continuity of care while maintaining boundaries. Discussing with family violates confidentiality, giving medical advice exceeds scope, and sharing personal information risks inappropriate bonds.
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The nurse aide is caring for a client with oxygen. Guidelines for safe oxygen therapy include:
Detailed Rationale
Inspecting skin for irritation from oxygen devices prevents pressure injuries. Low water levels reduce humidification, adjusting flow rates is outside scope, and removing devices interrupts therapy. Skin assessment is a key safety measure.
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When caring for a client with a leg brace, the nurse aide SHOULD:
Detailed Rationale
Keeping skin clean and dry under a brace prevents breakdown and infection. Reporting a secure fit is unnecessary unless thereβs an issue, removing the brace may be unsafe, and applying it to the wrong extremity is harmful. Skin care is essential.
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When giving mouth care to an unconscious client, the nurse aide SHOULD:
Detailed Rationale
Turning the head to the side allows secretions to drain, reducing aspiration risk. Avoiding teeth cleaning increases infection risk, giving mouthwash is dangerous for unconscious clients, and open curtains violate dignity. Proper positioning ensures safety.
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Which of the following items SHOULD be kept in the clean utility room?
Detailed Rationale
Clean utility rooms store unused supplies like specimen containers to prevent contamination. Soiled linen, used bedpans, and medications belong in designated areas to maintain infection control and security.
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The nurse asks the nurse aide to perform a task that the nurse aide has not been trained to do. The nurse aide's BEST response is to:
Detailed Rationale
Discussing concerns with the nurse ensures safety and may lead to training or reassignment. Performing an untrained task risks harm, delegating to another aide doesnβt resolve the issue, and coworker advice is not a substitute for professional clarification.
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"Scope of practice" refers to:
Detailed Rationale
Scope of practice defines legally authorized tasks based on training and regulations, ensuring safety. It is not defined by delegation, private business, or facility assignments, but by legal and professional standards.
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Pressure sores may be prevented by:
Detailed Rationale
Special care to reddened areas, like relieving pressure and keeping skin dry, prevents pressure sores. Minimal movement increases risk, wrinkled linens cause friction, and moisture softens skin, increasing vulnerability.
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An example of inappropriate communication with a 75-year-old client would include:
Detailed Rationale
Speaking to an older adult as a child is condescending and undermines dignity, known as elderspeak. Awareness of generational differences and sensory impairments aids communication, and addressing by name is respectful.
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When giving a complete bed bath to a client, the nurse aide SHOULD:
Detailed Rationale
Keeping the client covered preserves dignity and warmth. Perineal washing is essential for hygiene, moving around the bed ensures thorough care, and changing water prevents bacterial spread.
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When giving a complete bed bath to a client, the nurse aide SHOULD:
Detailed Rationale
Keeping the client covered preserves dignity and warmth. Perineal washing is essential for hygiene, moving around the bed ensures thorough care, and changing water prevents bacterial spread.
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If the nurse aide thinks a client is choking, the FIRST thing the nurse aide should do is:
Detailed Rationale
Asking if the client can speak determines if the airway is blocked. If they can speak, they may clear it; if not, immediate action like abdominal thrusts is needed. Removing food blindly or getting the nurse delays critical intervention.
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A difficult client yells for help immediately after the nurse aide leaves the room. How SHOULD the nurse aide respond?
Detailed Rationale
Entering and asking what the client needs shows responsiveness and de-escalates distress. Prioritizing another client or ignoring the yell neglects potential urgent needs. Scolding damages trust.
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A new nurse aide asks another nurse aide about the importance of the care plan. The nurse aide SHOULD tell the new nurse aide that:
Detailed Rationale
The care plan guides safe, individualized care, ensuring consistency and compliance. Nurse aides implement it, it changes with client needs, and dismissing it is unprofessional.
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A new nurse aide asks another nurse aide about the importance of the care plan. The nurse aide SHOULD tell the new nurse aide that:
Detailed Rationale
The care plan guides safe, individualized care, ensuring consistency and compliance. Nurse aides implement it, it changes with client needs, and dismissing it is unprofessional.
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