Documentation
Nurse Aide Action
Mobility
Nutrition and Hydration
Vital Signs
100

You offered a bath to Rich before supper and he stated he would take it before bed. About 8pm you offered Rich a bath or shower and he stated he was too tired and didn't want it. You will document...

Resident refused to complete activity

100

When caring for a person who is unresponsive, you 

Remember hearing is the last to go. Explain what you are doing to him or her.

100

A person has been on bedrest. You need to have the person walk. What will you do first?

Have the person dangle (or sit on side of bed) before getting out of bed.

100

A daughter asks you for water for her mom. You respond

I will be happy to do that.

100
A person has a blood pressure (BP) of 86/58mmHG. You

Report the BP to the nurse at one. Prepare to retake the BP again.

200
Transferring Penelope requires the use of a full-life and 2 staff. Penelope does not help. You will chart...

Total Dependence

200

A person you are caring for touches your buttocks several times. You

ask the person not to touch you again
200

You need to turn a heavy person in bed. You

Use good body mechanics. Get help.

200

A person is on a sodium-controlled diet. This means

Canned vegetabels are omitted from his/her diet

Sodium is limited in the preparation

200

When taking an apical pulse, count the pulse for 

1 minute

or if regular 30 sec (multiply by 2) or 15 sec (multiply by 4)

300

When assisting Harry with toileting, he walks to the bathroom with gait belt, one assist with walker. Harry takes his pants down and sits on toilet. Afterwards, you provide peri-care and Harry pulls his pants back on. You will document...

Partial or moderate assistance

300

You find a person smoking in the nursing center. You should

Ask the person to put the cigarette out and show them the designated smoking area

300

When transferring a person from a bed to a wheelchair, you never

Have the person put his or her arms around your neck

300

You are asked to encourage fluids for a person. You

Keep fluids where the person can reach them.

Offer fluids the person enjoys; increasing their fluid intake.

300

You are counting respirations on a person.  You

Count respirations when the person is unaware for 1 minute.


or if regular 30 sec (multiply by 2) or 15 sec (multiply by 4)
400

You place the walker in front of Daphne, who then stands up and walks to the dining room. You walk beside her with a grip on her gait belt. You will document...

Supervision or touching assistance

400

   When using a wheelchair, you should

Lock both wheels before you transfer a person to and from the wheelchair

400

A person has a weak left leg. What side should the person hold his/her cane?

Hold the cane in his/her right hand

400

Before feeding a person, you

wash your hands

400

You are taking blood pressures on people assigned to you. An older person has a blood pressure (BP) of 188/96mmgHG. You

Report it to the nurse at once. Prepare to take BP again.
500

You deliver Gary's meal tray to him. Open all the containers including the bag of chips. Place the fork in his hand and then he feeds himself. You will document...

Set-up or clean-up assistanc

500

When bathing a person, you notice a rash that was not there before. You

Tell the nurse and document it in the medical record

500

Restorative nursing programs help

promote self-care measures, highest-level of function
500

Jim is diabetic. The nurse administered insulin before the meal. Jim ate 25% of his meal and then walked away from the table.  You

Report to the nurse 

500

This morning you weighed Sally on the same scale as yesterday with similar clothing. Yesterday she weight 150#. Today she weigh 156#. You

Report to the nurse at one. Be prepared to weigh again.

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