vital sign questions

•The nurse asks you to take a patient’s blood pressure. You notice that the blood pressure cuff is a bit too small. You should:
Find a blood pressure cuff that fits the patient

Rationale: A blood pressure cuff that is too small or too big can make the result inaccurate. A patient’s treatment and blood pressure medications are adjusted according to results, and inaccurate results can lead to unnecessary changes. Always make sure the cuff fits appropriately according to the scale on the inside of the cuff.

•You are bathing your patient and you notice a small abrasion on her wrist that you haven’t noticed before. You should:
Notify the nurse of the abrasion after the bath

Rationale: Because the abrasion is on the wrist, the nurse can check it after the bath. If it is in a more discreet place like the buttocks, have another nursing assistant get the nurse. Never leave the patient alone while he/she is bathing. This is both a privacy and safety issue. Any skin issues that the nursing assistant thinks may be new should be brought to the attention of the nurse for him/her to evaluate and treat.

•The nurse should be notified of the following vital sign immediately:
Respirations of 28

Rationale: Respirations should be between 12 and 20. When a patient is sleeping, they can be as low as 8-10. If respirations are high, the patient is struggling to get enough air and is trying to breathe more rapidly to compensate. The nurse should be notified immediately because this patient may have an infection like pneumonia and will need evaluated further.

•The best time to do a skin assessment is:
While you are bathing the patient

Rationale: Doing a skin assessment while bathing the patient is the easiest and most efficient. Because the patient will already be undressed while being bathed, it is the best time to doing a quick assessment for any new skin tears, bruises, abrasions or reddened areas. It is unnecessary to undress the patient just to do a skin assessment and this takes away from their privacy. If there are any changes in the skin, notify the nurse.

•You would NOT need to report the following to the nurse:
An Alzheimer’s patient confused on what day it is

Rationale: In general, an Alzheimer’s patient being confused on the day isn’t something abnormal. Only abnormal things should be reported to the nurse. If you are unsure as to whether it is normal or not, report them and let the nurse decide the next course of action.

•You are taking a patient’s pulse. You know that the normal pulse range is:
60-100 beats per minute

Rationale: A pulse of 60-100 beats per minute is healthy. A pulse that is too high or too low isn’t efficiently pumping blood to the rest of the body. Because oxygen is in the blood, the body isn’t being properly oxygenated either. This can cause problems in every body system and the nurse should be notified of the pulse if it is too high or low.

•The following location is the most common place for skin breakdown on a patient:
Coccyx

Rationale: The coccyx is the most common place for skin breakdown to occur and for ulcers to start forming. The most pressure is usually exerted on this area due to patient’s sitting and laying down. This area should be checked everyday for changes, and any changes should be reported to the nurse. Pressure ulcers cost millions annually to treat, and the quicker it’s caught, the quicker it can be treated.

•A nursing assistant is allowed to do the following data collecting techniques:
Weighing the patient

Rationale: Part of a nursing assistant’s job is to weigh patients and report any dramatic changes to the nurse. All weights should be documented. Assessing a patient is not under the scope of practice for a nursing assistant unless they are checking the skin for new problems.

•You are checking a patient’s oxygen level with the pulse oximeter. It isn’t reading well, and you notice the patient has fingernail polish on. Your next action would be:
Removing the nail polish on one finger and trying again

Rationale: Nail polish can interfere with the machine’s ability to accurately determine a patient’s oxygen level. Simply remove the nail polish on the finger you are using and trying again. This should fix the problem. If not, the machine may be broken and you should get a new one.

•The nurse asks you to check a patient’s temperature. You know that you should never check a patient’s temperature if:
They just got done drinking a beverage

Rationale: Drinking or eating right before having an oral temperature taken can make the results inaccurate. Instruct the patient not to eat or drink for 15 minutes, and then return to the room and take the temperature. If the nursing assistant takes the temperature right after eating or drinking, it may give the wrong result and cause the patient to be unnecessarily treated.

•You would report the following patient complaint to the nurse:
A patient claiming a nursing assistant is abusing them

Rationale: Any claims of abuse should be reported to the nurse immediately so it can be investigated. Even if the patient doesn’t verbalize it and you suspect it or find bruises, you must still report it so it can be looked into further. Abuse is not only physical but can also be sexual, mental or emotional.

•You get ready to take a patient’s blood pressure knowing that a normal blood pressure is:
120/80 mmHg

Rationale: Blood pressure is the force that blood is exerting on the walls of the blood vessels. If it is too low or too high, it can be damaging to the body and have both short and long term effects. There is allowed to be a little bit of variation, but anything below 100/50 or above 150/90 should be a little concerning and the nurse should be notified. Some patients have chronically low or high blood pressure and these can still be normal, but that is for the nurse to determine.

•You should get report about the patient’s you are assigned to:
At the beginning of your shift

Rationale: As a nursing assistant, you must ask your nurses for any information you may need to take care of your patients safely and effectively. This will include their diagnosis, limitations, toileting habits, etc. You should always ask at the beginning of your shift, because that is when you will start taking care of your patients, not in the middle of your shift or on a break.

•A nursing assistant is responsible for documenting which of the following:
Intake and output

Rationale: Nursing assistants are responsible for documenting a patient’s intake and output, weight, mood, skin assessment, bathing and toileting routine, as well as a number of other things. Nursing assistants are not allowed to do physical assessments other than skin, give medications or treatments, therefore they will not document any information on that.

•Knowing about the patient's on the nursing assistants assignment is the responsibility of:
The nursing assistant that will be working with those patients

Rationale: It is the responsibility of the nursing assistant to know about the conditions, treatments, etc. of the patients they are caring for. It is their responsibility to ask questions about each patient as far as their toileting and bathing habits, how they ambulate and anything else related to the care the nursing assistant will provide. If a patient is injured because a nursing assistant did not get this information, they can be held accountable in a court of law for negligence and can lose their job and license.

•The following vital signs is abnormal and should be reported to the nurse immediately:
Oxygen saturation of 91%

Rationale: A normal oxygen saturation should be between 93% and 100%. Patients with chronic lung disease may have a normal oxygen saturation as low as 85%, but anything lower than 93% should be reported to the nurse immediately so she can decide if it is okay. If a patient is wearing oxygen, instruct them to breathe in through their nose and out through their mouth to improve their oxygen levels. Do not adjust the amount of oxygen they are receiving through their tank even if their levels are low.

•Your patient fell earlier and you now notice a bruise on their thigh. You should:
Notify the nurse

Rationale: Injures may not show up right away after a patient falls. Any new injuries should be reported to the nurse right away, even if they are expected. Assessing the patient for further injury is something the nurse will do when she checks on the bruised thigh.

•When checking a pulse manually, you will check it:
On the wrist

Rationale: When manually checking a heart rate, check the radial pulse located on the patient’s wrist. This will be on the palm side of the wrist, located below the thumb. Use your index and middle finger to do this, not the thumb. You can count the pulse for 15 seconds and then multiply it by 4. For the most accurate result, you should count for a full 60 seconds.

•It is important for the nursing assistant to document a patient’s vital signs because:
The nurses and physicians can see if there is any changes from the patient’s normal vitals

Rationale: The purpose of documentation is so that nurses and physicians can monitor any changes in a patient’s condition. Without knowing the pattern of vital signs, they won’t be able to tell if there is a variation from the patient’s normal condition or not. Although a patient has a heart rate of 90, their normal could be 60. This drastic difference can only be noted if vital signs are documented consistently. Make sure that all vitals are documented by the end of your shift, according to your employer’s policy.

•The following vital sign is abnormal and should be reported immediately:
Temperature of 100.7

Rationale: Anything above 100 degrees should be reported to the nurse for further evaluation. This is the first sign of an infection and it should be treated quickly.