NCE PRACTICE EXAM

A skilled nursing facility is also called a nursing home or long term care facility.

A hospital, while having skilled nursing positions, is not considered a skilled nursing facility, or SNF.  A rehab center would be a short term facility where patients can go to recover strength after surgeries. Hospice is the term for when a patient does not wish for any life-saving measures to be performed, such as CPR or intubation. A patient can be on hospice while residing in a hospital, rehab center, or nursing home.

Many elderly people who have had a stroke go to a subacute care center after they are discharged from a hospital. Subacute care centers, or medical rehabilitation care centers, provide stroke patients with rehabilitation and restorative care and services after a stroke. CNAs work in subacute care and they can also work in the other healthcare settings that are above.

A hospice (center) would be a location in which patients are cared for when nearing death. A respite center would be a temporary emergency location where a patient can receive care. A group home would be a long-term care living arrangement. A patient would be more likely to go to a sub-acute care center to regain strength prior to being discharged to their long-term home.

Team nursing involves multiple staff members providing different tasks in the care of the same group of patients. CNAs work in the team nursing setting, such as a sub-acute setting. The nurse and medical assistant would be necessary to provide some tasks such as medication administration and assessment, which are not within the CNA scope of practice.

Primary care involves one staff member caring for all the needs of the patient. Primary care nursing is usually implemented in a hospital floor setting. Group Care and Rehab are terms that usually indicate the location where a patient or resident may reside.

The finding should be reported to the nurse as the next step in the chain of command. The nurse will be able to assess the patient and report the findings to the provider.

The nurse should be notified prior to the provider. The CNA should not go directly to the provider as this does not demonstrate good teamwork or appropriate action. The Director of Nursing may be involved later if necessary, but the finding should currently be reported to the patient's nurse. It would not be appropriate to report the finding to the other CNA or delay the finding to report it after the CNA comes back from lunch. The nurse should be notified immediately as the patient may be having a heart attack.

If you are uncomfortable making a bed change, it is appropriate to ask for assistance, especially with an obese or immobile patient. If there is a risk of improper body mechanics, it would be appropriate to consider a two-person bed change.

If you attempt to change the bed yourself, you may be at risk to strain your back or use other improper body mechanics. The patient may also be put in improper positions to accommodate trying to change the bed. If possible, it is best not to push off tasks onto the next shift. If the patient has requested a bed change, they may be incontinent. The CNA should change the bed when asked within a reasonable time frame.

Taking vital signs and blood sugars readings would fall under a CNA's scope of practice and responsibilities in a team nursing setting.

Assessments can only be performed by an RN or LPN. Physical therapy exercise teaching should be performed by a physical therapist.

While it is appropriate for a CNA to orient another CNA to the responsibilities of the job, a CNAs cannot legally supervise, teach or mentor other CNAs. This is the role of the nurse, not the CNA.

You must refuse to do the assignment.  Supervision is not legally a part of the CNA role. You can be legally charged with unlicensed activity if you accept a job that is not within your legal scope of practice. Supervision is not within the scope of practice for a CNA.

The CNA should not even consider asking about the details. This is not within your scope of practice. You should notify the next person in the chain of command above the director of nursing if that staff member continues to pressure you to take the job.

Waiting to change the patient every 4 hours can cause skin breakdown if the patient is incontinent every hour. Changes should happen every 2 hours at the most, and a trained CNA should be aware of these standards.

It is appropriate for a CNA to wait right outside the bathroom door to give the patient privacy while urinating, wipe the patient's finger with an alcohol swab when taking a blood glucose level to get an accurate reading and to make sure the high-fall risk patient walks only with assistance in the hallways.

A CNA cannot change a patient's dressing immediately after surgery as this requires an assessment of the condition of the wound.

A physician, RN or LPN can legally make an assessment of the patient's incision and complete the dressing change.

Holding a certification, such as a Nursing Assistant Certification, is the minimal requirement to make a legal record of patient information.

A nursing or medical license would allow the person to make a legal record of patient data; however, a certification can be obtained prior to licensure. A college degree does not legally allow a person to record patient data.

Abraham Maslow developed the Hierarchy of Needs. Erik Erikson developed a framework of development tasks; Jean Piaget describes the thinking development of people, and Florence Nightingale is referred to as the Mother of Nursing.

 

The levels of Maslow' hierarchy are the physical needs, safety and security needs, love and belonging needs, esteem needs and self actualization. Assessment, planning, implementation and evaluation are phases of the nursing process. Subjective data, objective data, data analysis, open ended questions and close ended questions are parts and aspects of the interview process. Lastly, the integumentary, respiratory, nervous and cardiac systems are a few of our bodily systems.

A patient complaining of chest pain is the highest priority and should be reported to the nurse immediately.

A patient requesting a bed bath would be a low priority. Vital signs should be started as soon as the CNA reports the patient complaining of chest pain to the nurse. The CNA can start collecting trays as possible when entering patient rooms to complete other higher priority tasks.

It is not appropriate to refuse assistance to care for a patient within reason. The CNA should assist the nurse as much as possible prior to taking her lunch or request another staff member to assist with the patient's needs.

It is appropriate to delay your lunch if needed to assist the nurse. If getting a full lunch period becomes difficult, it should be discussed with the Director of Nursing. It is appropriate to ask for assistance from other staff members to meet a patient's needs.

Qid is the acceptable abbreviation for four times per day. These times, in most facilities, are 10 am, 2 pm, 6 pm and 10 pm.

Once per day is QD.
Twice a day is BID.
Three times a day is TID.

Stat is the acceptable abbreviation for immediately and without any delay. Doing errands, like bringing lab specimens to the lab, can be done by CNAs.

This is the appropriate abbreviation for vital signs every 4 hours.

Vital Signs QID indicates take vital signs four times a day but does not specify the time interval. QOD indicates to take vital signs every other day. QOD is also not recommended as an abbreviation. Vitals QD x 4 indicates take vital signs every day for four days, not every 4 hours.

The medical abbreviation ADL stands for Activities of Daily living.

In medical terminology, BKA means below the knee amputation. A BKA would be missing a lower limb below the knee.

A patient with tubes coming out of both kidneys has bilateral nephrostomies. A BKA would not indicate an elevated blood sugar. (This may indicate DKA, a medical diagnosis.). A patient with edematous legs may be suffering from CHF, or congestive heart failure.

The five senses are hearing, smell, taste, sight and touch. Auditory is the same as hearing and visual is the same as seeing. Common sense is not one of the five senses.

The five senses are sight, hearing, smell, taste and touch. Nursing assistants use sight, hearing and touch to observe their patients and residents. They use sight to read blood pressures and to see if the person is sleeping. They use hearing when they listen to the patient and hear their concerns. They use touch when they touch the patient's skin and feel that it is warm or wet. Common sense is not one of the five senses.

She should report the finding to the nurse. Only nurses can make assessments of a new open area on the skin. The sore should be reported to the nurse prior to applying barrier cream or any other intervention. Because this appears to be a pressure ulcer, it is unlikely the patient is aware it is there.

If the resident is choking with no sound, the best response is to perform the Heimlich maneuver.
Chest compressions are only appropriate if the resident does not have a pulse and is unresponsive. Slapping the residents back may cause the aspirate to move farther into the resident's airway. It is better to perform the Heimlich sooner. If possible, call for help prior to approaching the resident.

The first response should be to alert the nursing staff on the floor so they can make a documented assessment of the findings, then the correct personnel should be notified following the hospital protocol in reporting child abuse.

Unless the CNA feels she is not getting an appropriate response from other hospital staff, the CNA should follow the chain of command and the hospital protocol prior to getting Child Protective Services involved. The CNA should not question the child or confront the parents. This should be left to personnel trained specifically to handle domestic violence.

The elderly are at great risk for falls. Those in middle years are less at risk than the elderly population. COPD and pneumonia are not risk factors associated with falls.

Blindness is a sensory, visual impairment. Visual impairments, such as low vision and blindness, place patients and residents at risk for falls because they cannot see hazards as well as those who have good vision. Confusion is a thinking, or emotional problem that places people at risk for falls. However, it is not a sensory impairment. Muscle weakness is also a risk factor for falls, but it is not a sensory impairment. Aging is not a sensory impairment. 

Approaching the resident calmly and trying to verbally reorient and redirect the resident back to their room would be the first response. If the resident refuses to return to their room or becomes verbally or physically aggressive, it would then be appropriate to notify the nurse.

While physically touching the resident may be a secondary response, this would not be the best initial response as it may cause the resident to become physically or verbally aggressive. This could escalate into a unsafe situation for the resident. Unlocking a locked door in an Alzheimer's unit to allow the resident through would not be appropriate. The resident may become lost or could fall in an unfamiliar environment. It is appropriate to assist the resident back to their room; however restraints should only be applied by a nurse and with a provider's order. Other interventions should always be tried first.

It is best to notify the nurse or care manager as soon as possible as more experienced staff members may be necessary to prevent the situation from escalating further.

Telling the residents to stop arguing may exacerbate the argument and the CNA needs to remain impartial to the resident's conversation. A resident should not be moved to another room without instruction from the care manager or nursing supervisor. Pulling the curtain can help, but the residents will still argue with the curtain in place.

The best way to de-escalate an agitated patient is to talk in a slow and calm manner. Physically engaging with them or shouting may agitate the patient further.

Closing the door to the room may not be safe in a disoriented patient, who is at risk for falls. It is best to not physically touch the patient who is agitated unless they accept your assistance.

It is best to remove the syringe and place in an appropriate disposal container for sharps as soon as possible, note the patient's room that you found it in, and then report to the nurse as soon as possible.

You should not ignore the syringe; cleaning staff should not handle free syringes. Leaving the syringe also increases the risk for needle sticks. The syringe should be placed in the sharps container, not the trash can.

You should close the patient doors to prevent smoke from entering the rooms. You do not evacuate patients until you are instructed to do so. The RACE procedure states that the first thing you must do in the case of a fire is R, or rescue patients in immediate danger. There are no patients on your unit in danger. The next thing you do is A, or pull the alarm. The alarm was already pulled because you hear the alarms ringing. So, the next step, C, or contain the fire is done. You close the doors to contain the fire and smoke, not open them.

RACE is the procedure that tells you what you do in case of a fire. R is the first priority; A is the second thing you do; C is the third thing to do; and E is the last thing you do when the RAC of RACE are done. R stands for Rescue. A stands for Alarm. C means Contain the fire and E indicates that you should Extinguish the fire only if you can do so safely and the fire is small and contained. You will extinguish the fire if you can do so safely and without harm, because the RAC of RACE is already done. Nobody is in danger; you have pulled the alarm and the fire is small and contained. You should never open windows or cover a trash can fire with all materials, like a blanket that will likely burn.

A facility's Policy and Procedures Manuals need to obtain the most up-to-date procedures for responding to disasters, such as a fire, tornado, or winter storm.

Google Search may provide you with generic information, but not the most up-to-date procedure for the facility you are in. It is the duty of the CNA to be aware of the procedures themselves without having to rely on other staff members in the event of a disaster. The Human Resources handbook will provide information pertaining to pay grades, benefits, and interactions with other personnel.

Move patients away from outside windows to prevent debris and shattering glass from injuring the patient. All persons in the building should remain within the building and stay away from outside walls, doors, and windows. Appropriate actions should be taken to ensure patient safety; the building itself is not secure. The elevator should not be used during emergencies.

Ambulatory patients, children, and babies should be evacuated first during a fire. Immobile patients and patients on life support should be evacuated last. Patients requiring wheelchairs and walkers should be evacuated after ambulatory patients, then patients requiring transfer or stretcher assistance.

The best option is to attempt to detain the person through conversation or other means, as long as it is safe to do so, until security arrives and the appropriate staff can interact with a potentially dangerous suspect.

If a staff member blocks the exit from an aggressive offender, the person may harm the staff member. If the staff member attempts to take the bag from the person, they may become aggressive. It is better to wait for trained security members.

The patient should be placed as close to a regular sitting position as possible.

The positions in the other answer options would not be optimal as the patient's head is not elevated and these positions do not allow for easy swallowing. The patient is at risk for aspiration.

It is important to retract the foreskin of uncircumcised male patients in order to remove the smegma that collects under the foreskin. This smegma can lead to bacterial growth and infection. The foreskin is then replaced after the penis is cleaned.

The penis should be cleaned away from the tip to prevent infection, not towards it. The genital area should be cleaned prior to the rectal area to prevent infection. A new washcloth area should be used with every washing stroke to prevent infection.

It would be more appropriate for a nurse or podiatrist to trim the nails of a patient with Diabetic Neuropathy as performing this task may require some assessment skills. Assessment should only be performed by a nurse or provider.

A CNA should be able to safely feed any patients unless they are on a strict NPO diet or otherwise restricted by the Speech Pathologist. A CNA can ambulate a patient with a walker who is low-fall risk. A CNA can provide a bath to a surgical patient prior to a procedure, or after a procedure as long as the surgical incision is avoided.

Habitually ignoring the urge to defecate can lead to constipation and the accumulation of feces.

Diarrhea would be caused by a disease process or infection, not by ignoring the urge to defecate. Incontinence and hemorrhoids may develop over time from the patient pushing too hard to defecate.

The chain, or cycle, of infection includes the germ, or microorganism, the reservoir, the exit portal, the mode of transmission, the entry port, and the susceptible host. The types of immunity, not the chain of infection, include active natural immunity, active artificial immunity, passive natural immunity and passive artificial immunity. It is important to learn the cycle, or chain, of infection so you can stop the spread of infection by breaking one or more of these chains. For example, you will break the chain of infection when you stop the mode of transmission by washing your hands.

Asepsis is defined as the absence of disease causing germs. Aseptic techniques should be used to interrupt the chain of infection. It is surgical asepsis that is defined as the absence of all microorganisms, including spores. A pathogenic infection is an invasion of the body by a pathogen, or disease or germ, and a urinary infection is only one type of infection.

A patient with MRSA, or Methicillin Resistant Staphylococcus Aureus, would be placed on contact precautions. MRSA is a commonly known and widespread bacterium that is resistant to antibiotics.

A patient who is coughing is likely to be placed on droplet precautions, not contact precautions. A patient who just had hip surgery would require standard precautions, unless they were positive with a bacteria or virus requiring contact or droplet precautions. An elderly patient does not need to be placed on contact precautions just because they are elderly, only if infected with a bacteria or virus that requires higher precautions.

Standard precautions include hand washing or sanitizing, and wearing gloves when bodily fluids are present such as urine, stool, or sputum. Standard precaution assumes that all bodily fluids are considered infectious.

Gloves are only necessary when handling bodily fluids, otherwise hand washing between patient rooms is appropriate. A mask would only be required for droplet precautions. Hand washing is necessary when in a patient care setting at all times as a standard precaution.

You would most likely expect to see Reverse Isolation Precautions on a floor of patients with decreased immune systems, such as cancer patients. It is appropriate to wear a gown, glove, and a mask to prevent the spread of infection to these patients.

A surgical floor would be more likely to have Contact Precautions or Standard Precautions. An Obstetrics floor and Alzheimer's unit would not usually have Reverse Isolation Precautions.

All of the above choices are hazards of immobility. However, only the calcium loss from the bones is a skeletal system impairment that results from immobility.

Contractures are a muscular tightening due to immobility. Constipation is a gastrointestinal side effect with prolonged immobility. Catabolism is a chemical hazard related to immobility, not skeletal.

Depression is the correct answer. There are also emotional hazards of immobility. Some of these emotional changes are depression, poor decision making and a decreased self esteem.

Dementia, delirium and diversion are neurological hazards that can be aggravated by a prolonged stay in a hospital or unfamiliar environment. They may present similarly to emotional hazards but a neurological in function.

While falls are not an expected result of aging, patients in the elderly age group are at higher risk for falls due to weakness and comorbid conditions, such as Alzheimer's. These falls frequently cause injuries due to weakened bones as the body ages.

Middle-Aged and Young Adults are at lower risk for injury-causing falls. While children may fall frequently, these falls do not usually cause injuries.

Repositioning, applying skin barrier cream, and minimizing skin contact with urine or stool act as preventive measures against pressure ulcers. Contractures boots are placed to prevent contractures, not pressure ulcers. If not applied properly, they may increase the risk for pressure ulcers.

The wheelchair should be placed as close to the patient's strong side as possible to minimize the distance they need to travel to get positioned into the wheelchair.

If placed on the patient's weak side, this will create more difficulty as the patient will need to manipulate their weak side further to get into the chair. The chair should be placed on the patient's strongest side, regardless of whether that is the head or foot of the bed once the patient is sitting up.

Restraints are placed to prevent the patient from harming himself or others around him. They would not normally be considered a fall-risk intervention. Fall mats, bed or chair alarms, and non-skid socks are all commonly used as fall risk interventions.

It is not appropriate for the CNAs to discuss another patient's care in front of another patient, even if the patient is not fully oriented, as this is a violation of HIPAA and may cause further confusion in the patient they are caring for.

It is appropriate to stand on either side of the bed to help turn the patient, for one CNA to hold the patient up while the other CNA cleans the patient and for the CNAs' to boost the patient in bed using the draw sheet.

These signs and symptoms are most likely to indicate that the person is having a heart attack. The CNA must immediately report these signs and symptoms to the nurse. It is likely that this is a medical emergency. It cannot be ignored.

The patient has the symptoms and care indicative of congestive heart failure, not dementia or diabetes. People with congestive heart failure (CHF) have dependent edema of the legs. They have too much volume in their blood so the person will have a fluid intake restriction and a low salt diet. The person will also get daily weights to determine how much water weight the person is gaining or losing each day.

Diabetes and dementia would not present with edema, be required to have a fluid restriction, or low salt diet. Diabetes has to do with blood sugar regulation, and dementia is a neurological disorder. Contiguous heart disease is not a disease.

This is a diabetic patient who is presenting with symptoms of a low blood sugar, a common finding in diabetic patients in the hospital. The nurse will most likely request you to take the patient's blood sugar.

The patient's vital signs were normal one hour ago and he is presenting with signs of low blood sugar, sweating, tremors, and dizziness. While a Rapid Response or Code would be appropriate if the patient was unresponsive, this patient is alert and oriented. The nurse will most likely as you to check the patient's blood sugar and assist with any other tasks related to this patient who is symptomatic, prior to answering the call light of another stable patient.

Making sure the patient wipes from front to back is important to emphasize to prevent bacteria from traveling from the anus to the urethra.

Instructing the patient to stand up slowly will prevent orthostatic hypotension and potential falls. Making sure the patient presses the call light will be important in patients that are weak and at risk for falls. Helping the patient use proper body mechanics when standing will help to prevent strained muscles and improve movement.

A slow shuffling gait, jerky movements, and difficulty speaking, while being oriented, would be common signs of Parkinson's disease.

A patient with Alzheimer's may walk slowly but a shuffling gait and jerky movements of the arm are more symptomatic of Parkinson's disease. This patient is also oriented. These are not symptoms of heart failure or stroke and would not need to be reported to the nurse.

COPD would cause shortness of breath and requirement of oxygen therapy. The patient may require additional breathing medications at times which would be administered by the nurse or respiratory therapist.

Coronary Artery Disease would not cause shortness of breath, but may lead to heart attacks. Urinary Tract Infections and Constipation would not cause shortness of breath or require oxygen therapy unless there are respiratory complications.

Anticipatory grief is grief that is experienced before the loss or death. There are multiple stages in the grieving process and anticipatory grief is considered normal and healthy.

Unhealthy/abnormal types of grief include complicated grief, unresolved grief and inhibited grief. Complicated grief may occur if another tragedy happens at the same time for the person. Unresolved grief is grief that does not resolve over a set period of time, based on what would be expected. Inhibited grief may be a sign that the person has not accepted the tragedy, and may cause complications later on.

We must respect and uphold the cultural needs of our patients. You must immediately notify the nurse about this cultural need. It is possible that the nurse can accommodate the wishes of the family.

The CNA should notify the nurse to come assess the patient. Because this patient is on hospice, the nurse will then notify the doctor if the patient does not have a heartbeat. No interventions will be attempted as the patient is on hospice care.

A patient on hospice care would be considered DNR, or Do Not Resuscitate, therefore chest compressions or calling 911 would not be appropriate as this patient is deceased and does not want further intervention. Because there is no rise and fall of the breath, it would be more appropriate to check for a pulse or notify the nurse that the patient appears to be deceased. Shouting at the patient would not be appropriate.

A CNA should leave the determination of time of death up to the nurse to report to the physician. A CNA can report a suspected patient condition to the nurse.

A CNA can provide physical and emotional care for the patient and family during a hospice encounter, as well as making legal records of vital signs and care for the patient.