Critical Thinking

Question 1

Your client voices pain, what action would you take?

Answer 1

o Ask objective question, When/how much painful/where/how/how long
o Check client hx
o Check Pressure
o Report to the nurse STAT
o Follow nurse’s directions
o Report and record

Question 2

Your client voices pain to the rectum after a bowel movement, you note frank red blood. What
action would you take?

Answer 2

o Ask objective question, when start this pain, how severe
o Check client hx : hemorrhoid
o Pressure the rectum and check conscious
o Report to the nurse STAT
o Report and record
o Check the temperature before washing client

Question 3

Your client voices pain to both legs upon standing. What action would you take?

Answer 3

o Turning back to the bed, wheelchair, chair
o When/how much painful/where/how/how long
o Don’t be rush
o Report and record

Question 4

Partial bed bath: While assisting the client they voice they are getting short of breath. What action would you take?

Answer 4

o Stop partial bed bath and cover client
o Change the high Fowler position (lower : 15-30/ semi : 30-45 / high 45-90 (but we are in
45-60 in reality), orthopneic position : Sitting up (ortho) and leaning over a table to breathe
o Follow the care plan

Question 5

Partial bed bath: While assisting the client with a partial bed bath the client becomes increasingly
anxious voicing “are we almost done?” “can you hurry up?” What action would you take next?

Answer 5

o Stop and cover
o Ask client “are you uncomfortable? Do you want me to come back later?”
o If client said yes. Leave call bell. Record and report
o If client said no. Give them time and ask again “are you okay? Would you like to continue?”
Then do
o Record and report

Question 6

Dx UTI: Your client voices increased episodes of incontinence. What action do you take?

Answer 6

o Ask other symptoms (ask feeling_moderate or severe/ color/odour/ consistency of the urine)
o Note for the urine input and output
o Check fluid intake
o Report and record

Question 7

Hx Seizures: You note while repositioning client that they begin to have convulsions. What action
do you take?

Answer 7

o Stop repositioning
o Stand by, airway check
o Check for unsafe object around it
o Recovery position
o At least 3 min, if it’s over, hit the call bell

Question 8

Dx COVID/Asthma: Your client complains of chest pain, what action would you take?

Answer 8

o HOB up to high-fowler position
o Ask how are they feeling?
o Orthopneic position
o Ask them where is the pain? Scale rom 1-10 the pain? When they exhale or inhale is it hurt?
o Check care plan and MAR
o Record and report

Question 9

Dx hyperglycemia: Your client voices weakness and appears confused (can’t remember what day
it is or his last name), what action would you take?

Answer 9

o Check the care plans & MAR
o Ask the client’s feeling
o Report and record to the nurse

Question 10

Dx MRSA: While providing client care you notice the clients dressing on her elbow has come off
and there is drainage all over the bed. What action would you take?

Answer 10

o Get gauze and cover the elbow
o Transfer the client to a chair
o Changing occupied bed
o Report and record

Question 11

Dx. Osteoporosis with severe pain and already took medication

Answer 11

check with the nurse which temp.
pack can apply, how much time

Question 12

Mouth Care: While providing mouth care you note the client has a lot of secretions. What action
do you take?

Answer 12

o In this case is maybe unconscious
o Use toothies to clean and tongue depression to prevented chocking
o Record and report

Question 13

Denture care: When assisting the client to remove their dentures you notice the client’s gums
have white patches and bleeding. What action would you take?

Answer 13

o Stop removing it and Ask the client “ your gum is painful? How much? When it started?”
o Observation of white patches : size, swollen, bleeding countinuous or light
o Report to the nurse and record

Question 14

Complete bed bath: You note the clients skin becomes really warm to touch. What action would
you take?

Answer 14

o Check the temperature, skin condition
o Check the care plan
o Record and report

Question 15

Partial bed bath: While assisting the client with their partial bed bath they become agitated both
verbally and physically, pushing your hand away. What action would you take?

Answer 15

o Cover towel
o Step away (to respect their personal space)
o Ask what happen? How are they feeling? > I can com back later, do you need some time
to settle down
o Report to the nurse
o Record

Question 16

partial bed bath: You note client was incontinent of urine and was unaware, what action would
you take?

Answer 16

o Cover towel
o Provide bed pan
o Put continence pad beneath
o Check the observation of urine (color, odor)
o Ask any pain/ have you been done this before?
o Be calm and soft
o report and record

Question 17

Partial bed bath: You note while providing care that the client has developed a rash on their chest.
What action would you take?

Answer 17

o Ask the client discomfort, pain
o Observe rash (color, moisture or dry, size, location, warm)
o Report and record

Question 18

Shave: The care plan states to shave the clients face daily, however; the client is refusing. What
action would you take?

Answer 18

o Ask the client the reason for refusal
o Compromise : how about change the schedule every day to three times a week (ask about
client’s preferences)
o Report and record

Question 19

Female peri care: Upon providing peri care you note red patches to the client’s groin area. What
action wound you take?
*Note this is not excoriation.
A yeast/ fungal infection is often mistaken for excoriation.

Answer 19

o It could be a bedsore, infection from others
o Report to the nurse right away : location, size, color, dry, moisture(texture)
o Record and report
o Asking patients, how feel and pain.
o Finish the care with gently, pet dry

Question 20

Male peri care: While assisting with care you note the clients’ genitals to be red and excoriated.
What action would you take?

Answer 20

o Observe size, color, location, dry, moisture
o Ask client, did you have this for a long time? Or not?
o Report to the nurse
o Follow further instructions
o Record and report

Question 21

Ostomy care and bag change: You note the clients is a dark purple and appears dry. What action
would you take?

Answer 21

o Change ostomy 3-7 days
o Normal stoma color (red, moisture)
o If stoma color is purple and blue: report right away to the nurse.
o Follow further instructions
o Record and report

Question 22

Catheter Care: When providing catheter care to the client you note the 12-hour output as 100cc.
The client states they feel like they need to urinate. What action would you take next?

Answer 22

o 24 hours > 400 cc : normal > dehydration, UTI
o Leaking (incontinence pad, around tube) or kinking
o Observation of urine : color, odour, cloudy, amout
o Check the intake influid on the chart
o Ask the abdomen pain or floating.
o Record and report to the nurse

Question 23

Applying a condom catheter: While assisting with the application of the condom catheter you
note the client has a lot of hair within the area. What action would you take?

Answer 23

o Ask client “do you want to put it yourself?”
o if client said can’t, Push the hair aside
o Apply condom catheter and tape it
o Record and report

Question 24

Changing catheter drainage bag to a leg bag: When collecting supplies to switch the drainage
bag to a leg beg you note the that the catheter connecting port of the leg bag tubing has been
sitting on the ground. What action would you take?

Answer 24

o Clean the port with alcohol swabs
o Report and record (it might b contaminated and need the nurse to change

Question 25

Apply Ted Stockings: Client’s skin warm to the touch and client is voicing pain to calve/ back of leg. What action would you take?

Answer 25

o Not to apply ted stocking o Sign of thrombus or inflammation o Observation and gathering information o Redness or other new symptoms o Report and record to the nurse o Follow nurse’s further directions

Question 26

Apply compression stockings: Upon gathering compression stockings to assist in application the client refuses and states “they hurt and cut into my skin, they feel too tight.” What action would you take?

Answer 26

o Check any signs of swelling o Report to the nurse follow further instructions o Record and report

Question 27

Change gown (IV): While attempting to change the clients soiled gown you note they’re currently wearing a non-IV gown and have the IV hooked up and running. What action would you take?

Answer 27

o Take out the gown first at non IV side o Cover the client with the blanket or towel o Take out the IV side o Put on new gown IV side and then put on Non IV side o Record and report

Question 28

Observing condition of the skin: When observing the condition of the skin what are you looking for? What actions would you take when noting something abnormal?

Answer 28

*Observation of skin- pale, red, yellow, bluish-greenish, dark/ new scar o warm water and gently tend to the area o pet dry area o every toileting : giving hygiene o report and record

Question 29

Observe for abnormalities/ condition of the skin: You note the client’s stage 1 pressure ulcer to their coccyx has broken skin(stage 2) and appears shiny and very red. What action do you take?

Answer 29

*Observation of skin- pale, red, yellow, bluish-greenish, dark/ new scar o Get something to cover the skin then report to the nurse o Check the policy o Report and record

Question 30

You enter the room to find your client on the ground. They state they were trying to stand by themselves. What action do you take?

Answer 30

o need to check the client’s injury (blood): head to toe o check client conscious and breathing o follow the fall policy o report and record and chart and incident report o during shift, check this client carefully

Question 31

Sit to stand(this machine required that client can bear their weight) transfer to wheelchair: When setting up the client on the sit to stand you note the client is weak and unable to lift their feet/legs onto the machine platform. What action would you take?

Answer 31

o Ask question to client to check client is conscious. o Check client’s hx (MS) o Report to the nurse and can change machine or further care o Report and record

Question 32

Stand-by assist transfer to W/C: When setting up the client and equipment for a stand-by assist you note the right break on the wheelchair is not working. What action would you take?

Answer 32

o Report to the nurse o Follow policy to handle of broken wheelchair o Chart

Question 33

Transfer via full lift: When applying the appropriate sling to the client prior to the full lift the client states “I think I have a lot of strength today I might be able to stand”. What action would you take next?

Answer 33

o First, I said celebrate o Explain, why he can do on his-self. (Fall risk) o Give assertive conversation o Report and record. quoting

Question 34

Stand by assist with 4ww: While providing a stand-by assist to the client with their 4ww to the dining room the client becomes confused and believes he is to go to the bus stop, what action would you take?

Answer 34

o Be calm and ask softly further plan in his mind. o distract gently to go to dining room. o Report and record.

Question 35

Transfer via Sit to stand: While setting up sit to stand lift you note the breaks on the sit to stand are not working. What action would you take?

Answer 35

o Follow facility policy for broken equipment o Report to the nurse and explain to the client o Follow the further instructions o Record and report

Question 36

Sit to stand lift for transfer: While setting up the sit to stand lift you note the client is having difficulty following direction/ commands. What action would you take?

Answer 36

o Explain the procedure slowly and clearly (step by step) o Give time to the client o Report and record *if client confused or loss of strength* o Explain to client why I need to stop, get the consent. o Report to the nurse and follow further instructions. o If nurse said change to the mechanical lift

Question 37

Upon taking the VS the clients BP is ____ (abnormal) What action would you take?

Answer 37

Vital signs- : BP, TPR, O2 ; count respiration, get consent. Hand on back or hold arm and on the belly pretend check pulse. o Normal Bp, systolic 120/ diastolic 80 o Asking the feeling of dizziness, nausea, consciousness, normal breathing o Hypertension/ hypotension/ medication’s affect o Recording and reporting the nurse

Question 38

Obtain and record temperature: After taking the clients temperature another HCA opens the door and asks to borrow the thermometer. What action would you take?

Answer 38

o Said to the coworker wait for 5 min o It depends on the thermometer is owned by client or facility o If it’s owned by client, never borrow. Inform the co-worker report to the supervisor. o If it’s owned by facility, after finishing the care then carry out and give to the co-worker

Question 39

Taking a weight: When assisting the client to the scale you note the client becomes unsteady and is unable to stand on the scale independently. What action would you take?

Answer 39

o Stop the measure o Assist client to sit down o Ask the feeling and any dizziness o If client feels dizziness or confused. Observe abnormal signs such as pale, blue, redness face. Breathing. Vision for confused. Wait for a moment for client to be stable, but it’s not comfortable. Return to the client’s bed following the care plan. Report and record o If client doesn’t have strength only, report to the supervisor and follow further instructions such as changing chair scale, wheelchair scale or lift scale

Question 40

Administering a suppository: When attempting to insert the suppository, there seems to be a blockage. What action would you take?

Answer 40

o Call for nurse o Report and record o Follow further directions from nurse

Question 41

Your clients family members are at the bedside and begin to ask you questions such as “how long do you think our father will be around for?” “how is he doing? Is he getting better?” What action do you take?

Answer 41

o Oh, I really appreciate your questions, I think the nurse can be the better answers for you. So could you wait for it? I will go get the nurse o Report and record