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client on intake and output eats 1/2 cup of mashed potatoes, 4 ounces of cranberry juice, 7 ounces of milk, and a hot roast beef sandwich. What is the client's FLUID intake?
Detailed Rationale
Only liquids count for fluid intake: 4 oz cranberry juice (120 mL) + 7 oz milk (210 mL) = 330 mL. Mashed potatoes and sandwiches are solids and excluded.
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To prevent the spread of infection, the nurse aide SHOULD:
Detailed Rationale
Hand hygiene before and after tasks is the most effective way to prevent pathogen transmission. Extra linen, equipment on beds, or linen on the floor risks contamination.
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The nurse aide is caring for clients who are using bedpans. When will the nurse aide clean the bedpans?
Detailed Rationale
Cleaning bedpans after every use prevents pathogen spread and maintains hygiene. Delayed cleaning increases infection risk.
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A client states, "This splint feels different today." What should the nurse aide do FIRST?
Detailed Rationale
Notifying the nurse about a change in splint feel ensures clinical evaluation for issues like swelling or improper fit. Repositioning risks harm, documentation follows reporting, and delaying to the next aide is unsafe.
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The nurse aide is helping the nurse during group activity therapy for clients with dementia. This type of therapy provides clients an opportunity to:
Detailed Rationale
Group therapy stimulates cognitive function and social interaction in dementia clients, helping slow cognitive decline. Avoiding conversation, isolation, or staying in rooms contradicts its purpose.
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The nurse aide demonstrates good listening skills by:
Detailed Rationale
Waiting for clients to express thoughts shows respect and active listening, fostering trust. Continuing tasks, interrupting, or showing frustration undermines communication.
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A client may be dehydrated due to:
Detailed Rationale
Inadequate fluid intake directly causes dehydration, especially in those with reduced thirst or swallowing issues. Inactivity, excessive food, or salt-free diets do not directly cause dehydration.
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When the nurse aide is completing a task that requires gloves, the proper procedure for replacing a client's call light before leaving the room is to:
Detailed Rationale
Removing gloves and washing hands before handling the call light prevents pathogen transfer from contaminated gloves. Other options risk contamination or delay infection control.
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When removing a client's anti-embolism stockings, the nurse aide should report to the nurse IMMEDIATELY if the nurse aide observes that the client's toes are:
Detailed Rationale
Blue toes indicate cyanosis, signaling poor oxygenation or circulation, requiring urgent evaluation. Cold toes are less urgent, wrinkled skin is normal, and curled toes are not emergent.
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The nurse aide is working with a client who is on a bowel retraining program. Which of the following interventions will assist the client to have regular bowel movements?
Detailed Rationale
A high-fiber diet promotes regular, soft bowel movements. Restricting fluids or activity worsens constipation, and staying with the client supports emotionally but not physiologically.
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Which of the following is appropriate when communicating with a hearing-impaired client?
Detailed Rationale
Facing the client aids speechreading and comprehension. Standing beside removes visual cues, high pitch distorts speech, and exaggerated lip movements hinder lipreading.
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A client asks the nurse aide how the pressure injury on the heel will be treated. The nurse aide SHOULD tell the client:
Detailed Rationale
Redirecting to the nurse ensures accurate treatment information. Dismissing concerns, denying special care, or assuming dressings without confirmation risks misinformation.
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When plugging in a client's electric bed, the nurse aide receives a shock. The nurse aide SHOULD:
Detailed Rationale
Reporting a shock ensures the bed is taken out of service and repaired, preventing further risk. Continuing to use, retrying, or leaving a note delays safety measures.
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When giving care for a client who is confused and disoriented, the nurse aide SHOULD:
Detailed Rationale
Explaining care calmly reduces anxiety and builds trust. Encouraging confusion is unsafe, rushing care increases agitation, and detailed instructions overwhelm the client.
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What is the proper direction for washing a client's eyes?
Detailed Rationale
Washing from inner to outer side prevents debris from entering the nasolacrimal duct, reducing infection risk. Other directions risk contamination or miss critical areas.
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Which of the following is a sign that a client is having difficulty swallowing?
Detailed Rationale
Frequent coughing during meals indicates dysphagia, as food may enter the airway. Increased appetite, occasional coughing, or textured food requests are not direct signs.
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A client offers a favorite nurse aide a valuable necklace. The nurse aide SHOULD:
Detailed Rationale
Refusing a valuable gift maintains professional boundaries and prevents exploitation. Accepting or consulting the nurse implies acceptance, violating ethical standards.
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Which of the following requires a primary health care provider's order?
Detailed Rationale
Restraints require a provider’s order due to legal and safety implications. Cushions, snacks, and hand rolls are routine care measures not typically needing specific orders.
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How can a nurse aide get an answer from a client who is unable to speak because of a recent stroke?
Detailed Rationale
Using writing or gestures enables communication for clients with aphasia. Insisting on speech causes frustration, sign language assumes prior knowledge, and waiting for family delays care.
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Which of the following BEST describes guidelines for reporting by the nurse aide?
Detailed Rationale
Reporting before breaks and shift end ensures continuity of care. Reporting coworker’s clients is secondary, normal findings are not urgent, and delaying reports is unsafe.
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The nurse aide SHOULD respect clients of different cultures by:
Detailed Rationale
Being nonjudgmental honors cultural differences without imposing personal values. Encouraging spirituality may intrude, questioning family is not inherently respectful, and reacting to language risks offense.
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After moving a client with an indwelling urethral catheter, the nurse aide should first check that the catheter tubing is NOT:
Detailed Rationale
A kinked catheter obstructs urine flow, risking bladder or kidney issues. Checking for kinks ensures patency. Dirtiness, wetness, or visibility are secondary concerns.
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A client's care plan encourages fluids. The nurse aide SHOULD:
Detailed Rationale
Offering fluids between meals increases intake without affecting appetite. Limiting variety or removing pitchers reduces access, and temperature is individual preference.
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The nurse aide is caring for a group of clients with dementia. The nurse aide understands that these clients are at high risk for accidents because:
Detailed Rationale
Dementia impairs judgment, increasing risk of wandering into unsafe areas. Clients are not reliably aware of danger, and their cognitive abilities and judgment are diminished.
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What are common signs and symptoms in a client with lice?
Detailed Rationale
Lice cause itching and rash from scratching. Pain, blisters, sores, headaches, cyanosis, or dizziness are not typical symptoms.
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How SHOULD a nurse aide protect a client who wanders?
Detailed Rationale
Allowing walking in a secure area supports autonomy and safety. Bed confinement or restraints increase agitation, and activity rooms may not be secure.
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The nurse aide SHOULD make clients' beds without wrinkles in the sheets to prevent:
Detailed Rationale
Wrinkled sheets cause pressure and friction, increasing pressure ulcer risk. Contractures, fractures, and cyanosis are unrelated to bedding.
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Which elimination option should be offered to a client who can walk only a short distance?
Detailed Rationale
A bedside commode supports limited mobility, promoting dignity and safety. Briefs are for incontinence, urinals are for urination only, and bedpans require staying in bed.
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A client asks the nurse aide about the use of assistive devices. What SHOULD the nurse aide tell the client?
Detailed Rationale
Assistive devices promote independence and safety. They are not inherently difficult, not all clients need them, and use is not limited to once daily.
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When ambulating a client with a walker, it is important to make sure the client understands the instructions given by the therapist. What is a way to have the client show understanding of how to use the walker?
Detailed Rationale
A return demonstration confirms safe walker use. Repeating questions, rewatching videos, or using old methods does not ensure practical understanding.
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A client with diabetes has long toenails that are chipped and broken. The nurse aide SHOULD:
Detailed Rationale
Diabetic nail care requires trained professionals due to infection risks. Nurse aides should not cut nails or delegate to clients or family, but report to a supervisor.
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Which of the following items is disposable?
Detailed Rationale
Paper gowns are single-use to prevent contamination. Razors, commodes, and bedsheets are reusable with proper cleaning.
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How SHOULD a nurse aide respond if a client does not hear or does not understand something the nurse aide says?
Detailed Rationale
Facing the client and speaking clearly aids comprehension, especially for hearing-impaired clients. Quick speech, whispering, or loudness reduces clarity.
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When emptying an ostomy device, the nurse aide SHOULD:
Detailed Rationale
Observing output provides data on hydration or complications. Taping is for application, changing pouches every time is wasteful, and tight clothing risks dislodging the pouch.
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When providing postmortem care to a client, the nurse aide SHOULD:
Detailed Rationale
Maintaining dignity includes gentle handling and following cultural preferences. Prone positioning, deodorant, or opening the mouth are not standard practices.
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A client with terminal cancer tells the nurse aide, "I am going to die soon." The nurse aide SHOULD:
Detailed Rationale
Encouraging expression of feelings validates the client’s experience and provides comfort. Dismissing, discouraging, or redirecting to family avoids emotional support.
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When shampooing a client's hair, the nurse aide SHOULD take special care to keep the shampoo away from the client's:
Detailed Rationale
Shampoo can irritate or damage eyes, requiring protection like tilting the head or shielding. Ears, hands, and cheeks are less sensitive and lower priority.
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When transferring a client from the bed to a chair, it is necessary for the nurse aide to:
Detailed Rationale
Knowing the client’s abilities ensures safe transfer methods. Duration, extra help, or visitor clearance depends on assessment but is not the primary necessity.
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What would be the BEST equipment for a nurse aide to use when assisting a client with ostomy care?
Detailed Rationale
A specimen cup is the most appropriate equipment for ostomy care, as it is used to collect and dispose of output from the ostomy pouch, ensuring proper hygiene and accurate monitoring of the output. Urinals are for urinary collection, bedpans are for bowel movements in bed, and bedside commodes are for toileting, none of which are suitable for ostomy care.
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A sputum specimen is from the:
Detailed Rationale
A sputum specimen consists of mucus or phlegm coughed up from the lungs, typically collected for diagnostic testing to assess respiratory conditions. It does not originate from the bowel, bladder, or skin, which are unrelated to respiratory secretions.
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Which of the following is an example of a delegated task that a nurse aide might be asked to perform?
Detailed Rationale
Taking vital signs, such as temperature, pulse, and respiration, is a common delegated task within a nurse aide's scope of practice. Updating a client's family, performing specialized swallowing exercises, or removing an indwelling catheter are tasks typically reserved for licensed professionals like nurses or therapists due to their complexity and risk.
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To prevent the spread of infection, the nurse aide SHOULD:
Detailed Rationale
Practicing standard precautions, such as hand hygiene, using gloves when needed, and proper disposal of contaminated items, is the most effective way to prevent infection spread. Wearing gloves for all care is unnecessary and wasteful, while confidentiality and clients' rights, though important, do not directly address infection control.
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When cleansing the perineum of a client, the nurse aide SHOULD wash and dry from the:
Detailed Rationale
Washing from the genital to the rectal area (front to back) prevents the spread of bacteria from the anal area to the cleaner genital area, reducing the risk of urinary tract infections. Other methods risk contamination or are not standard practice.
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Which of the following tasks is carried out by the nurse aide?
Detailed Rationale
Taking temperature, pulse, and respiration is a routine task within a nurse aide's scope of practice. Assigning care, preparing care plans, and drawing blood are responsibilities of licensed professionals, such as nurses or phlebotomists.
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When the nurse aide is caring for a client, it is important to:
Detailed Rationale
Encouraging client independence promotes dignity, autonomy, and physical function, aligning with person-centered care principles. Doing everything for the client, rushing tasks, or dictating actions undermines the client's self-esteem and recovery.
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A nurse aide is caring for a client who cannot verbally communicate. The nurse aide SHOULD report:
Detailed Rationale
Grimacing upon getting up may indicate pain or discomfort, a significant observation that requires reporting to the nurse for further assessment. Normal or positive behaviors, like no difficulty or happiness, do not typically require immediate reporting.
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The nurse aide SHOULD know that fecal impaction:
Detailed Rationale
Fecal impaction occurs when constipation is not relieved, causing hardened stool to accumulate in the rectum, potentially leading to complications. It is uncomfortable, does not result in soft stool, and while an enema may help relieve it, it is not the primary method of identification.
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Which of the following is an example of client neglect?
Detailed Rationale
Leaving a client in wet clothes is neglect, as it compromises hygiene, comfort, and skin integrity, potentially causing infections or pressure ulcers. Other options may be inappropriate but do not meet the definition of neglect.
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Which of the following is a client advocate who acts on behalf of long-term care facility clients?
Detailed Rationale
An ombudsman is a designated advocate for long-term care clients, addressing complaints and protecting their rights. Dietitians, physicians, and clergymen focus on nutrition, medical care, and spiritual support, respectively, not advocacy.
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What is the appropriate temperature for a tub bath?
Detailed Rationale
A tub bath temperature of 105°F to 110°F is safe and comfortable, preventing burns or chilling. Higher temperatures risk scalding, and lower temperatures may be too cold for comfort.
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