Pearson VUE Flashcards
Hand washing
1) opening procedure
2) if the sink has one handle turn it to the center setting. If it has two turn both of them on.
3) wet hands starting at the wrists. Wiggle excess water off fingertips. (DO NOT FLICK FINGERS!!!)
4) apply soap. Use a generous amount. (It is okay to reapply soap during the washing phase)
5) lather for 25s while keeping fingertips down and hands lower than the elbows. Clean fingernails last (around the 20 second mark.)
6) rinse from the wrists with fingertips down making sure not to touch the sides of the sink or faucet. If you do happen to touch the side of the sink look to the NAE and let them know that you have contaminated yourself and ask “would you like for me to start the procedure over?”
7) after rinsing inspect the arms for any soap residue and wiggle fingers to remove excess water (do not flick the fingers!)
8) use elbow to access paper towels
9) start by drying the fingers of each hand individually. Proceed to dry from the wrist down.
9) use elbow to get more paper toweling and turn off the tap
10) dispose of paper toweling in the garbage
11) verbalize “skill complete”
Applying one knee-high elastic stocking
supplies: one knee-high elastic stocking
1) opening procedure
2) provide privacy with a curtain, screen or door
3) “I’m locking the bed Wheels”
4) “okay Ms Jones I’m going to go wash my hands and grab my supplies. Here is your call light in case you need anything. I’ll be back in a moment”
5) upon return knock and State “okay Miss Jones I’m back”
6) notify the client that “I’m raising the bed to a comfortable height for me to work with”
7) make sure the resident is in the supine position
8) place hand and arm in the stocking and pinch the heel. (The heel is usually blue)
9) keeping the heel pinched, pull the top of the stocking down the arm and over the hand making sure the top of the stocking is inside out.
10) “Miss Jones, I’m going to go ahead and uncover your leg”
11) stretch the stocking as wide as possible and place it over the foot up to at least the heel. Pull the remainder of the stocking over the foot and up the leg/over the calf
12) move the foot and leg gently and naturally, avoiding force and overextension of limb and joints
13) finish the procedure by ensuring that the blue portion of the heel is covering the client’s heel. Lift up the resident’s leg making sure that there are no twists or wrinkles in the stocking. The toes can either be open or closed. State to the NAE “the stocking is wrinkle free” after making final adjustments.
14) before readjusting the bed sheet say “okay Miss jones, you’re stocking is on and I’m going to cover you back up”
15) “I’m returning the bed to its lowest position for your safety” and place the call light within reach “and here is your call signal Ms Jones. If you need anything while I’m gone just go ahead and press that button”
16) “I’m going to open your privacy curtain and your door”
17) verbalize to the NAE
a) “I will wash my hands” (pantomime)
b) “skill complete”
Assists to ambulate using transfer belt
supplies: gait belt
1) opening procedure (“I’ll be assisting you with walking this morning.”)
2) “I’m lowering the bed into a safe position and locking the bed Wheels”
3) “here is your call light in case you need anything”
4) “I’m going to provide you with some privacy” by pulling a curtain, screen, or closing a door
5) “I’m going to go wash my hands and gather my supplies. I’ll be back shortly”
6) knock on door (bed) upon return and state “OK, Mr/Ms Jones, I’m back and I’ve got my supplies.”
7) place the call light to the side
8) “Misss Jones I’m going to lower the bed sheet now” lower bed sheet to the foot of the bed
9) state “I’m going to assist you into a seated position”
10) “I’m going to interlock my arm with your arm and place my hand behind your shoulder and on the count of three we’re going to sit up okay?”
11) count “one, two, three” and lift them into a sitting position
12) close the back of the gown as much as possible while verbalizing “I’m just making sure your gown is closed so the belt doesn’t chafe you” (IMPORTANT: this is to ensure that the gait belt DOES NOT touch bare skin or street clothes)
13) “okay, Ms. Jones, on the count of three, I’m going to swivel you around to the edge of the bed.” “1 2 3”
14) making sure to place your hand on the client’s back/shoulder ask “if you can, scooch up to the edge of the bed until your feet are flat on the floor” keep your hand on the client as they scooch. Recheck and adjust gown in the back if necessary.
15) do not allow the client to initiate putting on their shoes. You must offer first by stating “here are your shoes. Do you need help putting them on?”
16) “OK Miss Jones, this is a gait belt that I’m going to put around you in order to help you stand up. Can you raise your arms for me?”
17) place the belt around the client and fasten off to the side making sure the buckle is not over the belly button. Tuck in the excess. Check that the gown is closed in back.
18) “okay Miss Jones I’m going to stabilize your legs by placing my knees against yours”
20) “place your hands at your sides and when I stand you up you can push off with your hands. We will be standing on the count of three ok? One, two, three”
21) lift the client into standing position.
22) “now can you pivot to your right/left?” (Towards the foot of the bed)
23) always cup the belt with hands upward in a supinated position when lifting/walking. Assist them with walking while standing back and to the side. (If assisting an NAE walk them 10 steps forward and then 10 steps back while counting and announcing which direction to pivot in for the turnaround and for returning to the bed)
24) ask them to take a few steps back and then ask “can you feel the bed behind you?”
25) “Okay Mrs Jones on the count of three we’re going to sit you down. 1 2 3”
26) “can you raise your arms for me again?” remove the gait belt and roll up
27) “Miss Jones would you like to stay seated or would you like to lie down?” (Remove shoes if lying down)
28) return the call light to the client with “here is your call light.” Verbalize “I’m making sure the bed is in the lowest position and that the wheels are locked.”
29) a) If working with an NAE ask “would you like to maintain your privacy? Should I keep the curtain drawn?” and act accordingly.
b) if working with the dummy verbalize “I’m going to maintain your privacy” and leave the curtain drawn/door closed
30) verbalize “I’m washing my hands. Skill complete”
Assists with use of a bedpan
Supplies:
a) two pairs of latex gloves
b) toilet paper
c) hand wipes
d) standard bedpan
1) knock on door/bed
2) opening procedure
3) upon return “Hi Ms Jones, I’ve got my supplies and I’m ready to get you on the bed pan okay?”
3) lower the HOB if necessary while stating “I’m going to lower the head of the bed for you Miss Jones”
4) “now I’m going to raise the bed to a height that’s comfortable for me to assist you” while raising the bed
5) set the call light to the side
6) Don clean gloves
7) Ask, or if necessary, assist resident by raising their knees/drawing their feet towards the buttocks leaving them flat on the mattress
9) “Miss Jones can you raise your hips for me please?” lift the blanket and take care not to overexpose the resident. make sure the residents gown is not underneath them before placing the bed pan.
10) place the bedpan underneath the client with the narrow end facing the FOB
11a) “extends I have to go wash my hands before I can raise you into a functional position. I’ll be back in a minute”
11b) remove gloves and dispose of them in the garbage and verbalize “I will wash my hands”
12) “Miss jones, I’m going to raise the head of the bed so you’re in the most comfortable position to use the restroom” while raising HOB “let me know what height is good for you” “is that good? Ok”
13) “here’s your call light Ms Jones. Now I’m going to lower the bed into its lowest position”
14) “here is your toilet paper and your hand wipes” place them on the bed next to the resident
15) explain to the resident “Miss Jones I want you to use these hand wipes to clean your hands after you’re finished, OK?”
16) “I’m going to step behind the curtain to give you more privacy. Please press the button on the call light when you’re finished and I’ll be right in to assist you”
17) “knock knock” maintain privacy upon return and State “OK Ms Jones, I saw your call light. Now we’re going to go ahead and remove the bed pan, OK?”
18) Don clean gloves
19) “I’m going to lower the HOB for you”
20) Say “Miss Jones I’m going to raise the sheet so I can remove the bed pan” and lift the bed sheet being careful not to overexpose the resident and say “Miss Jones can you raise your hips for me?”
21) remove bedpan and say “Miss jones, I’m going to empty and clean this bedpan and put away my supplies. When I come back I’ll put you in a comfortable position, okay?”
22) place supplies in the designated dirty area (?)
23) empty the contents of the bedpan in the designated toilet.
24) rinse the bed pan and empty into the toilet
25) place the bed pan in the designated dirty area
26) doff gloves and place in the garbage
27) verbalize and pantomime “I will wash my hands”
28) “hi Ms Jones I’m back. Let’s get you into a comfortable position. Would you like the head of the bed raised or do you want to keep it in this position?” Leave bed in the flat position
29) closing procedure
30) verbalize “I will wash my hands” and “skill complete”.
Skill 5
Cleans upper or lower denture
Supplies:
a) emesis basin
b) denture paste or a toothpaste labeled denture paste
c) toothbrush
d) denture cup with lid and either an upper or lower denture
e) gloves
1a) verbalize “I’m washing my hands”
1b) gather the supplies making sure NOT to place anything in the emesis basin except for the toothbrush which must be placed in bristles up.
2) lay down paper towel next to the sink as a “clean barrier” and place all of the items on top of it
3) don clean gloves
4) line the bottom of the sink with a paper or cloth towel
5) turn water onto a MODERATE temperature (single handle should be in the center/2 handles should both be turned on)
6) moisten the toothbrush and apply a pea size squeeze of denture paste
7) remove denture cup lid and immediately rinse.
8) remove dentures and empty the bottom of the cup. Rinse
9) refill the bottom of the cup with moderate temperature water
10) rinse the dentures
111) begin cleaning the dentures with the toothbrush while verbalizing “I’m cleaning the gum surfaces of the dentures. Now I’m cleaning all surfaces of the teeth. Now I’m cleaning the bottom of the dentures. Now I’m cleaning the grooves in the roof of the dentures.”
12) rinse the dentures and place them in the denture cup, teeth up and secure the lid
13) rinse the toothbrush and place in the emesis basin, bristles up
14) turn the water off and remove the supplies from the clean barrier and set aside
15) dispose of the clean barrier and sink liner in the garbage
16) doff gloves and throw in the garbage
17) verbalize “washing hands” and “skill complete”
18) if the NAE does not instruct you where to take the supplies, drop them off in the designated dirty area
Counts and records radial pulse
1) opening procedure making sure to place signaling device within reach
2) verbalize “I’m washing my hands”
3) “Hi Ms jones, I’m back. I’m ready to count and record your radial pulse. Ok?”
4) “I’m going to raise the bed to a comfortable working position for me”
5) place my hand on their wrist towards the thumb side
6) look at the NAE and tell them when you are going to start and stop counting. Example: “I’m going to start and stop on the 6” and begin counting for 60 seconds
7) say “start/stop” when the hand lands on the six
8) closing procedure “okay Mr./Miss Jones your pulse was 74. I’m going to lower your bed into a safe position. The bed wheels are locked. You have your call light. Would you like me to open the curtains for you?”
9) verbalize “I’m washing my hands”
10) record pulse and sign my name
11) verbalize “I’m washing my hands. Skill complete”
Counts and records respirations
1) opening procedure
2) “knock knock. I’m back Miss Jones are you ready for me to count your respirations? Okay”
3) look for where you can see the rise and fall of their breathing. Is it more discernible in the chest, or the abdomen? (Ask the NAE if it’s okay to put your hand on their chest if it’s hard to discern rising / falling. If not, it is okay to raise the HOB)
4) look at the clock, tell the nae which number you’re going to start/stop
5) “start” begin counting respirations. “Stop”
6) “okay Miss Jones your respirations were 20. Is there anything else I can do for you at this time?”
7) closing procedure
8) verbalize “I’m washing my hands”
9) record respiration rate and sign
9) verbalize “I’m washing my hands. Skill complete”
Donning and doffing PPE (gown and gloves)
Supplies:
a) isolation gown
b) gloves
1) verbalize “I’m washing my hands”
2) pick up gown and unfold it making sure it does not touch the ground
3) facing the back opening of the gown place arms through each sleeve
3) tie the neck strap
4) secure the gown at the waist to making sure to cover as much clothing as possible. Pull down in the back to help cover as much clothing as possible.
5) pull cuffs of the gown halfway up the palm of the hand and slide gloves over the top
6) NAE well then ask for me to turn around
7) pinch the palm of one glove and remove. Crumple into a ball with gloved hand.
8) slip two fingers from ungloved hand underneath the remaining glove at the wrist and remove it by turning it inside out
9) dispose of gloves into the designated waste container without contaminating myself
10) unfasten the gown at the neck and the waist
11) remove gown at the neck by going underneath and pulling it out and away
12) while removing gown, hold gown away from body at arm’s length without touching the floor. Roll the gown away, keeping it inside out
13) dispose of gown and designated container without contaminating myself
14) verbalize “washing my hands.” “Skill complete”
Skill 9
Dresses client with affected (weak) right arm
Supplies: two button-down shirts
Helpful tips:
*Take off strong (left) side first
*Put on weak (right) side first
*When undressing and dressing weak (right) arm maintain support of both the wrist and elbow joints
*Ensure client remains covered from the chest down with sheet when undressing and dressing
*You may have client hold bed sheet in place with left arm and/or their chin
1) opening procedure
2) retrieve two shirts and ask the NAE which one they would like to wear. “here are two selections for you Ms Jones. Do you have a preference?” Neatly fold and place their selection on the bed to their right side. Raise the bed to a comfortable working height
3) set the call light to the side. ask the resident to sit up making sure not to overexpose the resident, keeping the bed sheet in place by placing hand up high on the torso underneath the chin. “Are you able to set up for me Ms jones?” Untie the gown in the back
4) remove the gown from the left (strong/unaffected) arm first. slide the gown over to the client’s right side underneath the bed sheet.
5) Then remove gown from the right (affected/weak) side. With an interlocking grip support the wrist and elbow joints of the right arm and slide the gown off the right arm
5) roll down out and away from you making sure it doesn’t touch your clothing and dispose of it in the soiled linen container
6) pick up the clean shirt and put my right arm through the right sleeve and gently support clients elbow and wrist with an interlocking grip. Slide shirt over their arm. Pull the front right panel out and lay on top of the bed sheet.
7) ask the client if they can hold the sheet in place under their chin while moving forward/sitting up “Miss Jones are you able to tuck the sheet underneath your chin and sit forward for me?”
8) place shirt behind and over their left shoulder. Lay them down and walk around to their left side
9) ask the resident to slide their left arm through the sleeve “can you slide your arm through for me?”
10) pull the front of the shirt over the bed sheet. it is not necessary to button the shirt
11) slide the bed sheet from underneath the shirt and place it on top of the client
12) closing procedure
“Okay Miss Jones we’ve got you dressed and ready for the day. Before I leave I’m going to…”
*Lower the bed into its lowest position
*make sure to leave the call light near their LEFT / STRONG hand
13) verbalize “I’m washing my hands. Skill complete”
Skill 10
Feeds client who cannot feed themself
Supplies:
a) two spoons
b) wet wipes/damp cloth
c) cup of water
1) opening procedure
2) place supplies on meal tray making sure that it has a name card
3) “knock knock” place tray on the over bed table
4) pick up the name card off the tray and ask the client to State their name. “Can you tell me your name?” (or check their ID band if working with a mannequin) put the place card back on the tray.
5) let the client know that you’ll be raising the head of the bed into the Fowler’s position. (75 to 90°, but get them closer to 90). Set the call light off to the side
6) adjust the bed and the overbed tray. Ask the NAE/client if they can see their meal.
7) verbalize “Miss Jones I’m going to clean your hands before we get started” wipe hands clean
8) sit in front of the client
9) tell the client what food and beverage they have on the tray “Miss jones, today you have… and you have water to drink”
10) ask the client what they would like to eat first
11) using 2 spoons scoop up a bite and with one spoon offer the client one bite of each type of food on the tray, telling the client the content of each spoonful
12) offer beverage after the first bite. Ask the client if they’re able to hold the cup themselves “are you able to hold the cup? Or do you need me to assist?”
13) ask the client/nae if they would like another bite of..(the next item) proceed to offer everything that is on the tray
14) ask the client if they’re finished. “Ok. Miss Jones I’m going to clean your mouth and hands, okay?” Move the over bed table out of the way
15) closing procedure *let the client know “I’m going to leave the bed in this position for you”
16) remove the tray
17) follow the nae’s instructions on where to place the meal tray. If none are given set in the designated dirty supply area. It is not necessary to clear the tray.
18) verbalize “I’m washing my hands. Skill complete”
Skill 11
Gives modified bed bath (face and one arm, hand and underarm)
Supplies:
a) bath basin
b) gown
c) one towel
d) three washcloths (one to wash the face. One to wash the arm, hand and underarm. One to rinse the arm, hand and underarm)
e) soap
f) gloves
Helpful tips:
*Remove the client’s gown after they test the water
*Be sure to place the towel underneath the client’s arm
*Do not forget to dry the client’s face with a towel
1a) opening procedure
1b) gather the supplies. Verbalize “I’m testing the water temperature” after filling the bath basin
2) “knock knock. I’m back.” Place the supplies on the overbed table
2b) “Miss jones, can you test the temperature of the water and let me know if it’s comfortable?”
3) I’m going to raise the bed to a comfortable working height for me” set the call light off to the side.
4) Don clean gloves
5) “Miss Jones I’m going to ask you to sit forward so I can remove your gown” untie in the back and (take care not to expose the resident’s chest or lower body) remove one arm at a time. Pull the gown out from underneath the bed sheet and ROLL the gown AWAY from you while simultaneously pulling it out from under the bed sheet. Place in the soiled linen container
8) Wet the washcloth. Wring it out. DO NOT APPLY SOAP!!! Fold washcloth into fourths. Begin with the eyes wiping from inner to outer. Use a clean edge for each stroke. Use the remaining 2 folds of the washcloth to clean both sides of the face. Flip the washcloth around and use two clean strokes to clean the sides of the nose.
9) hang the washcloth on the side of the basin. Grab the dry towel and pat the client’s face dry.
10) holding on to the towel, expose the right arm. Unfold the towel halfway lengthwise and place underneath the clients arm.
11) wet the second washcloth and apply soap. Work the soap evenly throughout the washcloth. Do not fold.
12) start by washing the fingers/nails individually and move on to the hand, arm, underarm.
13) place the washcloth over the side of the basin. Grab the third washcloth. Wet it, wring dry and rinse the soap off of the clients fingers, hand, arm and underarm.
14) place the washcloth over the side of the basin. Pat the arm dry using the towel underneath the arm.
15) place the towel on the over bed table. Cover the exposed arm with the bed sheet
16) put the clean gown on the resident by placing the gown over the bed sheet. Assist client with putting arms through the sleeves.
16b) “Can you go ahead and take your arm out for me?” Place the client’s arm through both sleeves
16c) “Miss Jones can you lift up for me so I can tie the back?” Spread the gown and pull the bed sheet out from underneath and place over the client.
17) make sure the client has their call light
18) “Ms Jones I’m going to put these supplies away. I’ll be back in a moment.”
19) place towels in the soiled linen basket
20) place soap in the designated dirty area
21) empty, rinse and dry bath basin in the SINK. Place in the designated dirty area
22) remove and dispose of gloves
23) verbalize “I’m washing my hands”
24) return to the client and ask if they are comfortable in their position. Adjust if necessary.
25) closing procedure
26) verbalize “I’m washing my hands. Skill complete”
Skill 12
Measures and records electronic blood pressure
Supplies:
Electronic blood pressure meter and cuff
1) opening procedure
2) have client lie in supine position or sit in a chair with arm positioned at heart level with palm up and the upper arm exposed
3) turn on the monitor
4) select the appropriate cuff size
5) find the brachial pulse by following the ring finger up to the elbow and slightly to the right. Mark the spot with your finger
6) place the sensor arrow on the cuff above finger marking the spot. Fasten the cuff
7) select the appropriate setting and start the blood pressure cuff. Let the client know “this may get a little tight, okay?”
8) if the coffee place to more than 200 mm of Hg then stop the machine and use the cuff on the client’s other arm.
10) when the blood pressure reading appears on the screen take the cuff off the client in store away near the device
11) closing procedure
12) verbalize “I’m washing my hands”
13) record the blood pressure. Sign name.
13) verbalize “skill complete”
Skill 13
Measures and records urinary output
Supplies:
a) one pair of gloves
b) measuring container
c) fracture bed pan with liquid
1) don gloves
2) pour the contents of the bedpan into the container without spilling or splashing
3) rinse the bed pan and pour rinse into the toilet. Without drying the bed pan, place it in the designated dirty area
4) measure the amount of liquid at eye level with the container on a flat surface. (If the level is between two measurements round up to the nearest 25 ml/cc)
5) commit measurement to memory
6) pour the contents of the container into the toilet.
7) rinse measuring container and pour rinse into the toilet
8) without drying the container, place it in the designated dirty area
9) remove and dispose of gloves
10) verbalize “I’m washing my hands”
11) record measurement. start by writing my name and the date. Record measurement under candidate reading / urinary output. Example: 25ml/cc
12) a) sign and b) date (again)
13) verbalize “skill complete”
Skill 14
Measures and records weight of ambulatory client
1) opening procedure
Just check if the bed is in it’s lowest position and the wheels are locked
2) “Miss Jones can you please sit up on the side of the bed for me?” (Unlike transferring / ambulation you do not have to assist the client to the edge of the bed)
3) “do you need help putting on your shoes?” “After your shoes are on can you put your feet flat on the floor for me?
4) “can you please stand up and walk towards the scale for me?”
5) set the scale to zero (all the way to the left) BEFORE the client steps on the scale. Zero out both the large and small bars.
6) stand beside the resident and offer assistance getting them on to the scale “Miss Jones do you need help standing on the scale?” “Ok, step to the center please”
7) start by guesstimating clients weight and move the larger weight accordingly
8) slide the top weight until the meter is floating in the center. Commit measurement to memory
9) Read the clients weight out loud and offer to assist them off the scale “Miss Jones do you need help stepping off of the scale?”
10) “Miss Jones you can go back to your bed now”
11) the NAE will now instruct you where to go
12) verbalize “I’m washing my hands”
12) record the measurement a) date b) my name c) check weight box d) enter the clients weight in the “candidate results” box
13) verbalize “skill complete”
Skill 15
Performs modified passive range of motion for one knee and one ankle
Helpful tips:
a) ensure the client is in supine position
b) ensure side rails are down
c) make sure to exercise the full range of the joint
d) continuously support underneath the knee and ankle joints
d) instruct the client before and during the exercise to let me know if they are experiencing any pain/discomfort
f) perform each exercise slowly. 3x each
1) opening procedure
“The nurse asked me to exercise your RIGHT knee and ankle”
2a) “Miss Jones before we get started I’m going to raise the bed to a comfortable working height for me”
2b) ensure that the client is lying in supine position. Pull the bed sheet back from the right leg, being careful not to overexpose the client
3) instruct the client to inform me if they are experiencing any pain or discomfort during the exercise.
4) place hands underneath the client’s ankle and knee making sure the backs of my hands are flush with the bed. While supporting the leg at the knee and ankle, lift the leg bending it to a 45° angle at the knee, returning the leg to the client’s starting position (flexion / extension). Count “one” and check in with the client after the first set. “Are you doing okay?” repeat two more times unless pain is verbalized.
5) make sure to move the joints gently, slowly and smoothly throughout the range of motion, discontinuing the exercise if the client verbalizes pain.
7) “now I’m going to exercise your ankle joint. Again if at any time you experience any pain or discomfort please let me know”
8) place left hand underneath the ankle making sure to maintain support underneath the ankle joint (not the heel) and lift 1-2 in above the bed
9) with the right hand bend the foot towards the client (dorsiflexion) then forward towards the foot of the bed (plantar flexion). Count “one.” “Are you doing okay?” Do this two more times. Count each set.
10) re-cover the client’s leg with the bed sheet
11) closing procedure
12) verbalize “I’m washing my hands. Skill complete”
