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DC CNA practice questions

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Question 1Personal Care and Activities of Daily Living

A nursing assistant is about to help a resident brush her teeth. What should the nursing assistant do first?

  1. Rinse the toothbrush under hot water for a full minute
  2. Perform hand hygiene and put on gloves Correct answer.
  3. Apply lip balm to the resident's lips before brushing
  4. Ask the resident to sign a consent form for oral care

Explanation

Hand hygiene is performed before any resident contact, and gloves are worn whenever contact with saliva, mucous membranes, or body fluids is likely. Oral care involves all of these, so gloves are required. Rinsing the brush or applying lip balm does not protect the resident or the assistant.

Question 2Personal Care and Activities of Daily Living

Which action best protects a resident's privacy during a bed bath?

  1. Asking the resident to keep a gown on for the whole bath
  2. Closing the door and draping the resident Correct answer.
  3. Bathing the resident only in the hallway
  4. Leaving the door open so staff can see in

Explanation

Privacy means closing doors and curtains and exposing only the part of the body being washed. A gown left on during a bed bath gets wet and soiled and does not allow the skin to be cleaned and checked. Bathing in a hallway is never acceptable.

Question 3Personal Care and Activities of Daily Living

How should the nursing assistant store a resident's dentures when they are not being worn?

  1. Wrapped in a paper towel in a bedside drawer
  2. Soaking overnight in bleach solution
  3. Left on the bedside table
  4. In a labeled cup filled with water Correct answer.

Explanation

Dentures are kept moist because they can warp or crack if they dry out, and they are stored in a labeled container so they are not lost or mixed up with another resident's. Paper towels dry them out and are easily thrown away by mistake. Bleach damages the denture material.

Question 4Personal Care and Activities of Daily Living

When helping a resident who has weakness on one side to get dressed, the nursing assistant should dress the…

  1. unaffected side first and undress it last
  2. affected side last and undress it first
  3. affected side first and undress it last Correct answer.
  4. affected side only while the resident is standing

Explanation

Clothing is put on the weak side first so the limb does not have to be pushed through a sleeve or pant leg against resistance, and it is removed from the weak side last for the same reason. The strong side does the work. This rule keeps the resident from straining or losing balance.

Question 5Personal Care and Activities of Daily Living

How should a resident's toothbrush be stored between uses?

  1. Bristles up in the resident's own labeled cup Correct answer.
  2. In a shared cup with the roommate's toothbrush
  3. In a closed plastic bag with the toothpaste
  4. Lying flat on the sink counter

Explanation

A toothbrush should air dry upright in its own labeled holder so it does not stay wet and grow organisms, and labeling prevents it from being mixed up with another resident's brush. A closed bag traps moisture, and sharing a cup spreads germs.

Question 6Personal Care and Activities of Daily Living

A resident's water pitcher is empty and she says she is thirsty. What should the nursing assistant do?

  1. Give the resident a few ice chips only
  2. Document that the resident refused fluids
  3. Tell the resident to wait until the next meal
  4. Refill the pitcher and offer fluids Correct answer.

Explanation

Fluids are offered whenever a resident is thirsty, and the amount taken is recorded on the intake record. Waiting or substituting a token amount risks dehydration and is not the resident's choice to make. The resident has not refused anything.

Question 7Personal Care and Activities of Daily Living

How should the nursing assistant clean a resident's eyeglasses?

  1. Hot water and a scrub brush, then air dried
  2. Lukewarm water and mild soap, air dried Correct answer.
  3. A dry paper towel, rubbed firmly on the lenses
  4. The dishwasher on a gentle cycle with the dishes

Explanation

Lenses are washed with lukewarm water and mild soap and dried with a soft cloth, which removes oils without scratching the lens or its coatings. Hot water can warp frames and damage lens coatings, and dry paper towels scratch. Eyeglasses are never put in a dishwasher.

Question 8Personal Care and Activities of Daily Living

Before leaving a resident in bed, the nursing assistant should…

  1. Move the call light out of reach so it is not pulled
  2. Leave the bed raised to waist height
  3. Raise both side rails on every bed for safety
  4. Lower the bed and keep the call light within reach Correct answer.

Explanation

The bed is left in its lowest position so a fall causes less injury, and the call light and personal items are placed within reach so the resident does not try to get up alone. Side rails are used only when the care plan orders them, because they can cause injury or entrapment.

Question 9Personal Care and Activities of Daily Living

When giving perineal care to a female resident, the nursing assistant should wash…

  1. front to back with a clean part of the cloth Correct answer.
  2. in circles around the perineum with one cloth
  3. back to front so the soiled area is cleaned first
  4. only while the resident is standing

Explanation

Washing from front to back carries organisms from the rectum away from the urethra and vagina, which helps prevent urinary tract and vaginal infections. A new area of the cloth is used for each stroke so soil is not moved back onto already-clean skin.

Question 10Personal Care and Activities of Daily Living

A resident who cannot turn herself is lying on her back. To help prevent pressure injuries, the nursing assistant should…

  1. Place a ring-shaped cushion under the sacrum
  2. Reposition her at least every two hours Correct answer.
  3. Rub the reddened areas briskly to improve circulation
  4. Keep the head of the bed raised to 90 degrees

Explanation

Pressure is relieved by turning and repositioning on a schedule, usually at least every two hours, along with keeping the skin clean, dry, and free of wrinkles. Reddened areas are never massaged because damaged tissue can be further injured. Ring cushions and a high head-of-bed angle increase pressure and shearing.

Question 11Personal Care and Activities of Daily Living

A resident who is incontinent of urine should be…

  1. placed on fluid restriction so she wets less often
  2. left in a wet brief until the next scheduled check
  3. catheterized so her skin stays dry
  4. checked often and changed promptly Correct answer.

Explanation

Urine left on the skin breaks it down and leads to irritation, fungal growth, and pressure injuries, so residents are checked on a regular schedule and changed as soon as they are wet. Restricting fluids causes dehydration and concentrated urine that irritates skin even more. A catheter is used only when medically ordered, not for convenience.

Question 12Personal Care and Activities of Daily Living

A resident with a weak right leg is moving from the bed to a chair. The nursing assistant should…

  1. Place the chair on the strong side, pivot toward the strong leg Correct answer.
  2. Place the chair on the weak side of the bed
  3. Stand on the weak side and pull the resident up by the arms
  4. Let the resident bear weight mainly on the weak leg

Explanation

The resident moves toward the stronger side so that leg supports the transfer, and a gait belt gives the assistant a safe hold without pulling on the arms. Pulling on the arms can injure the resident's shoulders and gives poor control. Weight bearing is placed on the strong leg.

Question 13Personal Care and Activities of Daily Living

A resident has trouble swallowing. Which action should the nursing assistant take at mealtime?

  1. Encourage her to talk while she is chewing
  2. Let her lie back in bed while she eats
  3. Give liquids through a straw so she drinks faster
  4. Sit her upright and offer small bites of food Correct answer.

Explanation

An upright position and small bites reduce the risk of food entering the airway, and the assistant watches for pocketing before offering more. Straws make fluid move too fast for someone with a swallowing problem, and lying back or talking while chewing increases choking risk.

Question 14Personal Care and Activities of Daily Living

A resident is unconscious. How should the nursing assistant provide mouth care?

  1. Pour water into her mouth to rinse it
  2. Wait for her to wake up, since mouth care can wait
  3. Use a toothbrush and toothpaste while she lies flat
  4. Turn her onto her side and use a swab Correct answer.

Explanation

An unconscious resident is turned onto her side so secretions drain out, and a swab or suction toothbrush is used while keeping fingers out of the mouth to avoid being bitten. Fluids are not poured into the mouth because she cannot swallow them. Mouth care is still needed on a schedule.

Question 15Personal Care and Activities of Daily Living

A resident's hair is matted and tangled. The nursing assistant should…

  1. Comb from the roots to the ends with a fine comb
  2. Cut out the matted sections with scissors
  3. Start at the ends and work upward in small sections Correct answer.
  4. Comb it while wet without using conditioner

Explanation

Working from the ends upward in small sections loosens tangles without pulling on the scalp or breaking the hair. Starting at the roots drives the tangles tighter together. Cutting hair is not the assistant's decision, and wet hair without conditioner breaks easily.

Question 16Personal Care and Activities of Daily Living

Which practice is correct when shaving a resident with a safety razor?

  1. Soften the beard and shave in the direction of hair growth Correct answer.
  2. Use the roommate's razor so supplies are not wasted
  3. Shave quickly before the beard has been softened with water
  4. Shave against the direction of hair growth for a closer shave

Explanation

A warm, wet washcloth softens the beard so the razor glides without scraping, and shaving in the direction of hair growth reduces irritation and cuts. Razors are personal items and are never shared. Shaving against the grain or on a dry beard causes razor burn and nicks.

Question 17Personal Care and Activities of Daily Living

While giving a bed bath to a resident with an indwelling urinary catheter, the nursing assistant should…

  1. Rest the drainage bag on the bed beside her
  2. Pull gently on the tubing to check that it is secure
  3. Disconnect the tubing so it can be cleaned well
  4. Wash outward from the meatus and keep the bag low Correct answer.

Explanation

Cleaning away from the meatus moves organisms away from the urinary opening, and the drainage bag stays below bladder level so urine flows out and does not back up into the bladder. Tubing is never pulled or disconnected, and the bag never rests on the bed, where it can contaminate linens and allow backflow.

Question 18Personal Care and Activities of Daily Living

During range-of-motion exercises a resident says, "That hurts." The nursing assistant should…

  1. Give her an over-the-counter pain reliever
  2. Push through the pain so the joint does not stiffen
  3. Stop all exercise for that resident from then on
  4. Stop the movement and tell the nurse Correct answer.

Explanation

Exercises are done only to the point of resistance, never past pain, because forcing a joint causes injury. The assistant stops, reports the pain, and follows the nurse's direction about how much motion is safe. Nursing assistants do not give medications or unilaterally discontinue a prescribed exercise program.

Question 19Personal Care and Activities of Daily Living

Why does the nursing assistant avoid shaking linens when making an occupied bed?

  1. It can wake the resident who is resting
  2. It damages the linen cart
  3. It wrinkles the clean sheets
  4. It can spread microorganisms into the air Correct answer.

Explanation

Shaking linen releases dust and microorganisms into the air, where they can be inhaled by the resident or land on surfaces and other equipment. Linens are folded gently and held away from the body. Wrinkles are prevented by smoothing the sheets, not by avoiding shaking.

Question 20Personal Care and Activities of Daily Living

A resident wears a hearing aid. How should the nursing assistant care for it when it is not in use?

  1. Store it overnight in a glass of water
  2. Leave it in place while the resident bathes
  3. Clean it with hot water and a toothpick
  4. Turn it off and keep it in a labeled case Correct answer.

Explanation

Hearing aids are damaged by moisture and heat, so they are switched off, the battery is removed when it will not be used, and the aid is stored dry in a labeled case. Water is never used to clean the device, and it is removed before bathing or hair washing.

Question 21Personal Care and Activities of Daily Living

While bathing a resident, the nursing assistant sees a dark purple area on the resident's heel that does not blanch when pressed. What is the best action?

  1. Keep pressure off the area and report it Correct answer.
  2. Write it in the care plan at the end of the shift
  3. Apply a heating pad to the area for warmth
  4. Massage the area to bring blood to the skin

Explanation

A non-blanching purple area may be a deep tissue pressure injury, and massaging or heating it can cause further damage to tissue that is already injured. The area is offloaded and reported to the nurse right away so treatment can start. Waiting until the end of the shift delays care.

Question 22Personal Care and Activities of Daily Living

During a meal a resident suddenly coughs, cannot speak, and has trouble breathing. What should the nursing assistant do first?

  1. Stop feeding, stay with her, and call for the nurse Correct answer.
  2. Give her a sip of water to clear the food
  3. Lay her flat and keep feeding slowly
  4. Leave the room to look for help in the hallway

Explanation

These are signs of an airway obstruction, so feeding stops at once, the resident is not left alone, and the emergency response is activated by calling for help. Giving fluids or laying her flat can worsen the blockage. Leaving the resident alone is dangerous.

Question 23Personal Care and Activities of Daily Living

A resident has a hand contracture on the left. Which action best supports the hand?

  1. Support the hand on a pillow as the care plan directs Correct answer.
  2. Place the hand under her back while she sleeps
  3. Tie the hand to the side rail to keep it straight
  4. Force the fingers open several times a day

Explanation

Contractures are managed by following the care plan, which may include positioning the hand around a rolled washcloth or splint and supporting the arm so the shoulder is not pulled. Tying the hand is a restraint, and forcing the fingers open tears tissue and causes pain.

Question 24Personal Care and Activities of Daily Living

A resident with mild dementia refuses a shower, and the care plan calls for two showers a week. What should the nursing assistant do?

  1. Insist on the shower because the order must be followed
  2. Offer choices such as a partial bath and tell the nurse Correct answer.
  3. Have a coworker hold her arms during the shower
  4. Document the refusal and stop all bathing

Explanation

The resident has the right to refuse care, so the assistant respects the refusal, offers acceptable alternatives such as a partial bath or a different time, and reports the refusal so the nurse can address the cause. Forcing or physically holding a resident is restraint and abuse.

Question 25Personal Care and Activities of Daily Living

A resident with diabetes has a small cut between her toes. What should the nursing assistant do?

  1. Apply medicated powder between the toes
  2. Trim the loose skin with scissors
  3. Soak the feet in hot water for 30 minutes
  4. Report it and keep the feet clean and dry Correct answer.

Explanation

Residents with diabetes heal poorly and develop serious infections from small wounds, so any break in the skin is reported to the nurse and foot care is limited to gentle cleaning and thorough drying. Soaking in hot water, cutting skin, and using medicated products on the assistant's own initiative can cause burns or infection.

Question 26Personal Care and Activities of Daily Living

A resident removes her dentures before bed. How should the nursing assistant store them?

  1. Keep them in the mouth so they do not change shape
  2. Wrap them in a tissue and put them in the drawer
  3. Place them in a labeled container filled with water Correct answer.
  4. Leave them in a dry cup on the bedside table

Explanation

Dentures are made of material that warps when it dries out, so they are kept covered in water or denture solution. The container should be labeled with the resident's name so the dentures are not lost or mixed up with another resident's.

Question 27Personal Care and Activities of Daily Living

The nursing assistant is preparing a tub bath for a resident. Which water temperature is appropriate?

  1. About 120°F (49°C), which feels hot to the hand
  2. About 105°F (40°C), tested on the inner wrist Correct answer.
  3. Cool water, about 90°F (32°C), to prevent dizziness
  4. As hot as the resident can stand, about 115°F (46°C)

Explanation

Bath water is kept near 105°F (40°C), which is warm but not hot, because older skin is thin and burns easily. The assistant checks the temperature with a thermometer or by testing the water on the inner wrist before the resident gets in.

Question 28Personal Care and Activities of Daily Living

In which situation should the nursing assistant wash her hands with soap and water instead of using an alcohol-based hand rub?

  1. After touching a resident's intact skin
  2. After caring for a resident with Clostridium difficile Correct answer.
  3. Before adjusting a hearing aid that is not in use
  4. Before entering a resident's room

Explanation

Alcohol-based rubs do not destroy the spores of Clostridium difficile, so soap and water is required after contact with a resident who has this infection. Soap and water is also used whenever hands are visibly soiled.

Question 29Personal Care and Activities of Daily Living

A nursing assistant is about to give a bed bath. Which action best protects the resident's dignity?

  1. Close the door and curtain and keep the resident covered Correct answer.
  2. Give the bath quickly and without talking to the resident
  3. Turn on the television so the room is not quiet
  4. Ask the roommate to leave the room until the bath is over

Explanation

Privacy is protected by closing the door and curtain and exposing only the body part being washed at that moment. The assistant also explains what she is doing and asks before removing clothing or linens.

Question 30Personal Care and Activities of Daily Living

A resident has weakness on the left side. When helping the resident put on a shirt, what should the nursing assistant do?

  1. Have the resident push both arms in at the same time
  2. Put the shirt on the weak left arm first Correct answer.
  3. Put the shirt on the strong right arm first
  4. Dress the resident with the arms crossed over the chest

Explanation

Clothing is placed on the affected or weak side first, then on the strong side, because the resident can use the strong arm to help finish dressing. The reverse rule applies for undressing: the strong side comes out first.

Question 31Personal Care and Activities of Daily Living

A resident has an order for elastic stockings. When should the nursing assistant apply them?

  1. Right after the resident returns from a walk
  2. In the morning, before the resident gets up Correct answer.
  3. Only on days when the resident reports swelling
  4. At bedtime, after the legs have been elevated

Explanation

Elastic stockings work best when they are put on before the resident gets out of bed, while blood has not yet pooled in the legs. The assistant removes them for bathing and skin checks at least twice a day and inspects the skin for redness or breakdown.

Question 32Personal Care and Activities of Daily Living

A resident has an indwelling urinary catheter. Where should the drainage bag be kept?

  1. Below the bladder, not touching the floor Correct answer.
  2. Resting on the floor beside the bed
  3. Hanging on the side rail above the bladder
  4. Attached to the front of the resident's gown

Explanation

The bag is kept below the level of the bladder so urine drains by gravity and cannot flow back into the bladder, which would cause infection. It must also stay off the floor, where it could pick up germs.

Question 33Personal Care and Activities of Daily Living

When trimming a resident's fingernails, how should the nursing assistant cut them?

  1. Trim the nail as short as it will go
  2. Cut in a deep curve at the corners of the nail
  3. Use scissors to cut down to the nail bed
  4. Cut straight across and file the edges smooth Correct answer.

Explanation

Fingernails are cut straight across and then filed smooth so the edges do not catch on clothing or scratch the skin. Cutting deeply into the corners can lead to ingrown nails and infection.

Question 34Personal Care and Activities of Daily Living

The nursing assistant is helping a resident use a bedpan. Which action is correct?

  1. Leave the room until the resident calls
  2. Dust powder on the rim before use
  3. Place the pan on top of the bed pad
  4. Raise the head of the bed for the resident Correct answer.

Explanation

Raising the head of the bed puts the resident in a more normal position for a bowel movement and makes it easier to bear down. The assistant stays nearby, checks on the resident often, and provides perineal care and handwashing afterward.

Question 35Personal Care and Activities of Daily Living

The nursing assistant is giving a resident a back massage. Which action is correct?

  1. Massage through the gown to save time
  2. Use an alcohol rub to cool the skin quickly
  3. Use lotion and avoid reddened areas over the spine Correct answer.
  4. Massage firmly directly over the reddened area

Explanation

A back massage uses lotion and gentle strokes over the muscles beside the spine to improve circulation and comfort. Any reddened or broken area is avoided and reported, because pressing on it can further damage tissue.

Question 36Personal Care and Activities of Daily Living

A resident can dress himself but takes a long time. The care plan says to encourage independence. What should the nursing assistant do?

  1. Allow extra time and help only when needed Correct answer.
  2. Hurry the resident by finishing the buttons herself
  3. Dress the resident to save time on a busy morning
  4. Skip dressing until the resident can go faster

Explanation

Promoting independence means giving the resident time to do what he can and stepping in only for the parts he cannot manage. Doing tasks for a resident who is able to do them leads to loss of function and self-esteem.

Question 37Personal Care and Activities of Daily Living

A resident is blind and needs help at mealtime. What should the nursing assistant do?

  1. Set the tray down and leave the room quietly
  2. Feed the resident the whole meal with a spoon
  3. Mix all the foods together in one bowl
  4. Tell the resident where each food is on the plate Correct answer.

Explanation

Describing the location of each item, often using clock positions, lets the resident find and eat the food himself. The assistant stays available, offers help as needed, and describes what is on the tray before the meal begins.

Question 38Personal Care and Activities of Daily Living

A resident with arthritis in the hands has trouble holding a toothbrush. Which action best supports independent mouth care?

  1. Use a sponge swab instead of a toothbrush
  2. Ask the nurse to schedule mouth care less often
  3. Pad the toothbrush handle so it is easier to grip Correct answer.
  4. Brush the resident's teeth for him every time

Explanation

Adapting the tool, such as thickening the handle with foam or a washcloth, lets the resident keep doing his own mouth care despite limited hand strength. Brushing with a soft toothbrush also cleans better than a sponge swab.

Question 39Personal Care and Activities of Daily Living

A resident who had a stroke has weakness on the right side and is sitting in a chair. Which position is best?

  1. Perched on the edge of the chair with the feet dangling
  2. Seated upright with the weak arm supported on a table Correct answer.
  3. Reclined with the legs stretched straight out
  4. Slumped toward the weak side with the arm hanging

Explanation

Sitting upright with the weak arm supported prevents the arm from pulling on the shoulder and reduces the chance of pressure and shear injury. The feet should rest flat on the floor or on footrests so the body weight is distributed evenly.

Question 40Personal Care and Activities of Daily Living

A resident has an IV line in the left arm and needs a gown change during a bed bath. How should the nursing assistant remove the gown?

  1. Remove the gown from the IV arm first
  2. Cut the gown off with bandage scissors
  3. Disconnect the IV tubing so the gown slides off
  4. Remove the gown from the arm without the IV first Correct answer.

Explanation

The gown is taken off the arm without the IV first, then the sleeve is gently worked over the IV bag and tubing while the line is supported. This keeps the IV in place and avoids pulling on the site.

Question 41Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

Which oral temperature reading for an adult is within the normal range?

  1. 96.0°F (35.6°C)
  2. 94.6°F (34.8°C)
  3. 98.6°F (37.0°C) Correct answer.
  4. 100.8°F (38.2°C)

Explanation

Normal adult oral temperature falls between about 97.6°F and 99.6°F (36.5°C to 37.5°C). A reading of 98.6°F (37.0°C) sits in the middle of that range and is not a concern. Readings outside the range are reported so the nurse can evaluate the resident.

Question 42Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

Which resting adult pulse rate is within normal limits?

  1. 48 beats per minute
  2. 112 beats per minute
  3. 132 beats per minute
  4. 76 beats per minute Correct answer.

Explanation

The accepted normal resting adult heart rate is 60 to 100 beats per minute. A rate of 76 falls inside that range. Rates below 60 or above 100 are documented and reported for further evaluation.

Question 43Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

Which artery is most commonly used to measure a resident's pulse?

  1. Brachial artery
  2. Popliteal artery
  3. Carotid artery
  4. Radial artery Correct answer.

Explanation

The radial artery at the thumb side of the wrist is easy to reach, comfortable for the resident, and safe to press. It is the standard site for routine pulse counting. Other sites are used when the radial pulse cannot be felt or when a specific assessment is needed.

Question 44Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

The nursing assistant raises the head of the bed so the resident is sitting up at about a 60-degree angle. Which position is this?

  1. Prone position
  2. Trendelenburg position
  3. Fowler's position Correct answer.
  4. Sims' position

Explanation

Fowler's position is a semi-sitting position in which the head of the bed is raised 45 to 60 degrees or more. It helps with breathing and eating and is often used for residents with shortness of breath. Sims' and prone positions involve lying on the side or abdomen.

Question 45Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

A resident reports dizziness when getting up. To check for orthostatic hypotension, the nursing assistant should:

  1. Take one blood pressure reading while the resident stands quietly
  2. Take the blood pressure in the arm that has an intravenous line
  3. Take the blood pressure lying, sitting, and standing Correct answer.
  4. Take the blood pressure right after the resident climbs stairs

Explanation

Orthostatic hypotension is a drop in blood pressure when a person changes from lying to sitting to standing. The comparison requires readings taken in each position, usually with the pulse as well. Activity or an arm with an IV line would distort the measurement.

Question 46Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

For which resident should the nursing assistant measure temperature by mouth instead of rectally?

  1. A resident who had rectal surgery last week Correct answer.
  2. A resident who is on a low-sodium diet
  3. A resident who wears hearing aids
  4. A resident who has a fractured wrist

Explanation

A rectal temperature is avoided after rectal surgery, with rectal bleeding or diarrhea, and in residents who are confused or at risk of injury. An oral or axillary route is used instead. Diet and hearing aids do not affect the choice of temperature route.

Question 47Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

The nurse asks the nursing assistant to obtain an apical-radial pulse. How is this done?

  1. Count the apical pulse for 15 seconds and multiply by four
  2. Count the radial pulse for one minute and subtract it from an apical rate taken later
  3. Two staff count the apical and radial pulses at the same time for one full minute Correct answer.
  4. Count the radial pulse first, then the apical pulse for one minute each

Explanation

An apical-radial pulse compares the heartbeats heard at the apex with the beats felt at the wrist. Both must be counted simultaneously by two people for a full minute so that a true difference, called a pulse deficit, can be calculated. Sequential counts cannot be compared.

Question 48Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

A blood pressure cuff that is too small for the resident's arm will most likely produce:

  1. A reading that changes with each breath
  2. No measurable reading at all
  3. A reading that is lower than the true pressure
  4. A reading that is higher than the true pressure Correct answer.

Explanation

A cuff that is too narrow or too short must be inflated to a higher pressure to compress the artery, so the reading comes out falsely high. The cuff bladder should wrap around roughly 80 percent of the arm. An oversized cuff tends to give a falsely low reading.

Question 49Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

What is the most reliable way for the nursing assistant to learn whether a resident is in pain?

  1. Watch for grimacing when the resident moves
  2. Check whether the resident's pulse is elevated
  3. Ask the family how the resident usually acts
  4. Ask the resident to rate the pain on a scale Correct answer.

Explanation

Pain is a subjective experience, and the resident's own report is the most reliable source of information. Standard pain scales give a consistent way to record intensity and response to treatment. Observation and vital signs are useful supplements but cannot confirm or rule out pain.

Question 50Basic Nursing Skills (vital signs, positioning, specimen collection, wound and catheter care)

Which action will help the nursing assistant obtain the most accurate pulse oximetry reading?

  1. Warm the resident's hand and place the probe on a bare finger Correct answer.
  2. Place the probe on the arm that has a blood pressure cuff
  3. Place the probe on a finger with an intravenous catheter
  4. Place the probe on a finger that has nail polish

Explanation

Pulse oximetry measures how much light is absorbed by oxygen-carrying blood, so anything blocking light or reducing blood flow distorts the result. A warm, bare fingertip gives the best signal. Nail polish, cold hands, and sites with a blood pressure cuff or IV interfere with the reading.