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Answer Rationales

  1. D. The two primary goals of bathing is protection from harmful bacteria and promoting the well-being of the residents. Removing soil and promoting an increase in skin moisture (A) is incorrect because bathing might increase skin dryness, not decrease it. Promoting relaxation of the resident and decreasing need for mobility (B) is incorrect because residents require mobility to decrease morbidity. Increasing circulation and decreasing incidence of pressure ulcers (C) is incorrect because pressure ulcers are decreased by cleanliness and frequent change of position along with proper nutrition.
  2. D. Nursing assistants are not to apply medications, because they do not have a license, training, or knowledge to administer medications. The statements in choices A and C are incorrect because the nursing assistant is planning to administer the medication, which is not part of his or her role. The statement in choice B is incorrect due to the use of improper communication.
  3. C. Normal oral temperatures are between 96.8°F and 100.4°F. Placing the thermometer in the mouth under the tongue in the sublingual pocket (A), waiting 10 minutes if the resident has consumed any hot or cold liquids (B), and using thermometer covers on all residents (D) are all steps used to determine the oral temperature.
  4. B. The normal adult heart rate is between 60 to 100 beats per minute. A pulse rate of 84 (A), 76 (C), and 66 (D) are within the normal range.
  5. D. Bradycardia is the heart rate below 60 beats per minute. Tachycardia is a slow heart rate (A) is incorrect; Tachycardia is the heart rate above 100 beats per minute. An irregular heart rate should be taken for at least 30 seconds (B) is an incorrect statement because irregular heart rates are to be obtained for one full minute. The carotid site is used most often to obtain the pulse (C) is incorrect; the radial site is used most often to obtain a resident’s pulse.
  6. A. Normal blood pressure for an adult is less than 120/80 and pre-hypertensive is less than 139/89. The blood pressure readings of 120/74 mm Hg, 140/68 mm Hg, and 130/70 mm Hg in choices B, C, and D are within normal limits.
  7. C. Residents should be weighed at approximately the same time each day. Having the resident remove shoes (A) and voiding (B) before being weighed, and calibrating the scales to zero each day or routinely (D) are part of the procedure for assuring accurate weighing of the residents.
  8. B. Change in a resident’s condition is serious and should be communicated to the nurse immediately. (A) Asking a fellow nursing assistant is not correct because assessment of the resident is not part of the nursing assistant’s role. (C) Assumptions might lead to harm of the resident. (D) The first and most important action of the nursing assistant in this situation is to communicate immediately to the nurse the change in the resident’s condition.
  9. B. Pressure ulcers are more prone to develop in bony areas. The heels (A), elbows (C), and knees (D) are areas with the highest incidence of pressure ulcers, which are located on bony surfaces.
  10. D. At least two washcloths and towels will be needed. One is for clean areas and the other for areas considered dirty. This is done to prevent spread of organisms. Keeping the room free from drafts (A), assuring the resident’s privacy (B), and warming the bath water to at least room temperature (C) are correct. The room is to be free of drafts and the room temperature should be between 68°F and 74°F to prevent chilling. Resident’s privacy is to be maintained at all times. Bath water temperature should be warm to promote comfort, help relaxation of muscles, and prevent chilling but not hot to risk injury to the resident.
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