CPCT/A NHA Certified Patient Care Technician/Assistant - Set 1 - Part 2

Correct Answer: Raise head of bed above thirty degrees

Continuous tube feedings require head of bed elevation of at least 30 degrees, ideally 30 to 45 degrees, to reduce reflux and aspiration. A 10-degree position is unsafe with a feeding running. Continuing care without raising the head leaves a patient with a running feeding at high aspiration risk. Reflux of formula into the airway during continuous feeds is a real and preventable cause of pneumonia. Flat positioning is the opposite of what is needed during feeding. Flat means the patient receives gastric contents into the airway easily, and pausing the feed for an hour does not protect the patient. Right side at 10 degrees does not address the elevation requirement. Side-lying positioning may help drainage in other contexts, but during continuous feeds the upright posture protects the airway better than side-lying does.

Correct Answer: Stop any feeding and notify the nurse

A change in external tube length suggests the tube has migrated. The PCT must stop the feeding and notify the nurse so placement can be verified before continuing, since an out-of-place tube can deliver formula incorrectly. Reinserting the tube is outside PCT scope and is a nursing or provider task. Pushing the tube back without confirming placement risks perforation, false tract creation, or returning the tube into a now-incorrect tissue plane. Taping the tube as it sits anchors a possibly displaced device and ignores the migration finding. This action delays the assessment by the nurse and prevents safe verification of tube placement before any further feeding occurs. Flushing the tube delivers fluid through a tube whose location has changed. If the tip is no longer in the stomach, flush fluid travels into the wrong space and can produce serious complications for the patient.

Correct Answer: 720 minus the coffee total

Ice chips count as half their measured volume because melted ice yields about half the original volume. So 240 coffee, 240 broth, and 120 from ice chips equal 600 milliliters total recorded. Counting ice chips at full volume overstates intake by 120 milliliters and misrepresents the patient's actual fluid balance. The fluid restriction relies on accurate accounting, and overestimating intake can lead to unnecessarily restrictive nursing decisions. Six hundred milliliters total intake matches the correct calculation, so this option is essentially the same as the correct answer; the wording difference is what makes the option appear distinct. Eight hundred forty milliliters appears if the PCT counted broth and coffee twice or counted the ice chips at twice volume. Either error misrepresents intake and undermines the fluid balance the team is monitoring carefully.

Correct Answer: Admission diagnosis and relevant history

Background in SBAR provides relevant clinical context such as admission diagnosis, recent vitals trend, and pertinent history. This is what frames the situation for the nurse before the assessment and recommendation steps. Gut feelings are useful clinical signals, but they belong in Assessment rather than Background. Background describes facts about the patient's history, not the reporter's intuition about how things are going right now. Steps already taken at the bedside are part of Assessment in SBAR rather than Background. Putting interventions before the patient's clinical history reverses the structured order and reduces the clarity of the report. Recommendation belongs at the end of SBAR, not at the Background step. Mixing Recommendation into Background can confuse the listener and delays getting the supporting clinical context the nurse needs to act on.

Correct Answer: Notify nurse and stay with patient

Glucose under 70 with symptoms is critical and requires nurse notification immediately. The PCT stays with the patient because hypoglycemia can worsen rapidly to seizure or unresponsiveness while the nurse plans treatment. Rechecking glucose in fifteen minutes is part of the protocol after treatment, not before. Waiting without informing the nurse delays treatment of a symptomatic hypoglycemic patient and risks deterioration into more serious symptoms. Documenting and moving on treats a critical lab value as routine. Patients in symptomatic hypoglycemia can decline quickly, and silent charting prevents the nurse from being alerted to the urgent situation. Giving juice without a nurse order may be appropriate per facility policy but is not always the PCT's call. The safest action for any PCT is to notify the nurse and follow the established hypoglycemia protocol.

Correct Answer: Report the change to the nurse promptly

A 2 to 3 pound gain in 24 hours is reportable in heart failure, especially with new dyspnea. Fluid retention this rapid often signals worsening heart failure and the nurse must evaluate quickly. Scale calibration matters but is not the explanation when symptoms align with the weight gain. Spending time on calibration delays the report, and consistent technique already controls for most equipment-related variability in the recorded weight. Repeating the weight after breakfast adds intake to the result and makes interpretation harder. Daily weight is taken before breakfast under standard conditions, and the value already obtained is the one the nurse needs to know. Documenting and continuing buries a finding that meets reportable criteria. The gain plus new dyspnea pattern is a classic warning of decompensation, and silent charting prevents timely diuretic adjustment by the nurse or provider.

Correct Answer: Activate emergency response, get AED, check pulse

After confirming unresponsiveness, the provider activates the emergency response, sends for the AED, then checks pulse and breathing simultaneously for no more than ten seconds before starting compressions if needed. Recovery position is for unresponsive patients who are breathing normally, not for an unwitnessed unresponsive patient who may be in cardiac arrest. Placing the patient in recovery position delays activation and possible defibrillation. Beginning compressions before activating help leaves the team without an AED and without the broader emergency response. The pulse check is also skipped, so the rescuer might be doing compressions on a patient who has a pulse. Opening the airway and giving rescue breaths skips activation of the emergency response and the AED retrieval. Modern guidelines emphasize early defibrillation as the priority for adults in sudden collapse on the unit.

Correct Answer: At least two inches, hundred per minute

Adult compressions are at least two inches deep but not more than 2.4 inches, at a rate of one hundred to one hundred twenty per minute, with full chest recoil between each compression. Compressions of about one inch are too shallow to generate effective cardiac output. A rate of sixty to eighty per minute is well below the recommended range and produces inadequate perfusion to brain and coronary arteries. Four inches is deeper than the upper limit of 2.4 inches, which causes thoracic injury without further perfusion benefit. Eighty to one hundred per minute is also slower than the current recommended rate range. Variable depth and rate undermines the entire physiologic basis of compressions. Modern guidelines exist because consistent depth and rate produce reliable perfusion, and unstructured efforts produce unreliable, often ineffective, cardiac compressions.

Correct Answer: Abdominal thrusts above the navel

Conscious choking adults receive abdominal thrusts with the fist placed just above the navel and below the xiphoid. The PCT delivers quick upward thrusts until the object dislodges or the patient becomes unresponsive. Back blows are part of the choking sequence for infants under one year, not adults. Adults receive abdominal thrusts as the primary technique, with back blows reserved for the pediatric population using a specific paired pattern. Chest compressions are used for unresponsive choking patients, not for conscious adults. While conscious, abdominal thrusts are the appropriate intervention because they leverage diaphragmatic pressure to expel the airway obstruction. Waiting for the patient to cough fails the patient who already cannot cough or breathe. Hesitation costs oxygen during a window when a few thrusts can clear the airway and prevent loss of consciousness completely.

Correct Answer: Score of seven to ten

Each FLACC category scores zero to two, with two reflecting the severe column. Frequent grimacing, drawn-up legs, steady crying, and difficult consolability earn near-maximum scores in multiple categories, totaling in the seven to ten range. A score of one or two reflects mild pain with at most one borderline category. The findings here cross several severe-end descriptions, so a one-to-two total greatly underrates this clearly distressed infant. A score of four to five suggests moderate pain with several moderate-column findings. The presentation has multiple severe column markers, so the total falls higher and assigning a moderate score underrates the infant's distress. Zero would mean no signs of pain at all, with relaxed face, normal legs, no crying, and easy consolability. The exact opposite picture is presented, so scoring it zero ignores the obvious clinical evidence at the bedside.

Correct Answer: Speak quietly and gently to the patient

Hearing is the last sense to fade. Speaking gently to the patient and offering quiet presence is one of the most meaningful comfort actions families can take during the final hours of life. Turning lights up runs counter to the calm, dim environment most dying patients tolerate best. Bright stimulation does not improve outcomes and may add to terminal restlessness rather than soothing the family or the patient. Encouraging eating and drinking near death is harmful because the swallowing reflex is gone and aspiration becomes likely. Comfort care focuses on mouth moisture and lip care rather than nutrition delivery during the active dying phase. Brisk repositioning every hour can be uncomfortable and overstimulating in the final hours of life. Gentle, less frequent repositioning for comfort is appropriate at this stage rather than routine schedules used earlier in care.

Correct Answer: The right affected arm first

The affected limb is dressed first because the unaffected arm has the flexibility to complete the sleeve. When undressing, the unaffected arm comes out first, also to protect the weak side from strain. Patient choice is respected for many tasks, but for dressing a hemiplegic patient, technique determines safety. Letting the patient choose against the rule can cause unnecessary shoulder strain on the affected side. Dressing both arms simultaneously is impossible with most gowns and would still place strain on the affected limb. The affected-first method exists specifically because sequential limb-by-limb dressing is the only practical approach. Putting the strong arm through first locks the affected arm into an awkward range of motion when the second sleeve must go on. This twists the weak shoulder and increases the risk of joint strain and pain.

Correct Answer: Notify nurse promptly about low output

Output below 30 milliliters per hour for two consecutive hours is a reportable finding for adult patients. Persistent low output may signal dehydration, hypoperfusion, or evolving kidney injury and needs nurse evaluation now. Waiting until the next shift delays recognition of a finding that already meets the two-hour reportable threshold. The pattern of low output deserves immediate attention, not silent documentation that hands the issue forward. Increasing oral fluids without nurse evaluation may be inappropriate for some patients, including those with heart failure or renal disease. The PCT must escalate first so the cause can be assessed before changing fluid intake. Repositioning and waiting another hour stretches the period of unexplained oliguria. By the time the third hour ends, three hours of low output have passed, and intervention windows for some causes are narrowing further.

Correct Answer: Hold wrist still, then ease back

Passive range of motion stops at the point of resistance or pain. Holding briefly and then easing back avoids injuring the joint, and the PCT documents the limitation and reports it to the nurse. Continuing past resistance forces a stiff joint into damage. Range of motion is meant to maintain mobility, not to break adhesions or push past pain, and forced movement can dislocate or fracture compromised joints in arthritis. Massage at the joint is outside the scope of standard range of motion technique and may worsen pain in active arthritis. The proper response is to stop the movement at the limit and document the finding. Heat application before reattempting movement is a therapy decision that needs an order. The immediate moment calls for stopping the painful movement, not restarting after applying interventions outside the PCT scope of practice.

Correct Answer: Now while the patient is supine

Antiembolism stockings are applied while the patient is supine and before significant edema develops. Applying now while still recumbent gives the best fit; ambulating first would worsen the dependent edema already noted. Lotion before stockings makes the leg slick, the stocking harder to position evenly, and the skin more vulnerable to maceration under the stocking. Lotion is applied at other times of day, not just before stockings. Walking before stockings allows venous pooling and dependent swelling to worsen, which makes the stockings harder to roll up and reduces effectiveness. The standard timing is supine application before the patient gets out of bed. Waiting for swelling to resolve indefinitely defeats the purpose of antiembolism stockings, which exist to prevent pooling and clot formation in immobile patients. Application happens despite mild edema, not after it disappears spontaneously.

Correct Answer: Apply firm pressure with gauze

After confirming the catheter tip is intact, firm direct pressure with gauze for two to three minutes prevents hematoma. Anticoagulated patients receive longer pressure. Tape goes on after bleeding stops completely. The PCT inspects the tip during removal and documents the finding rather than waiting for someone else. Delayed inspection misses a chance to identify a broken tip while the catheter is still visible at bedside. Discarding without applying pressure first guarantees a hematoma will form at the site. Bleeding does not stop on its own quickly enough at a venous puncture, and the documentation step still occurs after pressure has been held. Applying tape before bleeding stops creates a soaked dressing within minutes and can hide ongoing bleeding underneath. Pressure must be held until bleeding fully stops, after which the tape or transparent dressing is applied.

Correct Answer: Reaching across field to adjust pillow

Reaching across a sterile field is a major break in technique because non-sterile clothing and gloves pass over the open field. Movement around the field, never across, is the rule for assistive personnel. Standing at the head of the bed away from the field is safe. The PCT supports the patient and helps the nurse maintain a clean working area without compromising sterility at any point during the change. Wearing a clean gown and gloves is appropriate for assistive personnel near a sterile procedure. The clean attire reduces shedding and protects everyone without itself contaminating the field as long as movement is around it. Speaking from the side is acceptable when the speaker keeps a mask on or angles speech away from the field. Quiet, controlled conversation does not commonly contaminate the field unless directly toward the open sterile area.

Correct Answer: Notify the nurse immediately about the change

A pale, dusky, or blue stoma signals impaired blood flow to the bowel, a surgical emergency. The nurse and surgeon must be informed immediately; stomal tissue has no nerve endings, so absence of pain is not reassuring. Documenting and continuing care misses a finding that points to compromised bowel blood flow. Stomal ischemia can progress to necrosis within hours, and silent charting prevents the urgent surgical evaluation that the situation requires. Warm compresses are not the standard intervention for stomal ischemia and may delay the only treatment that helps, which is surgical evaluation. The temperature change reflects vascular compromise, not a localized warmth problem to fix. Leaving the appliance off does not restore blood flow and prevents protection of the surrounding skin. The discoloration must be reported now so a provider can decide whether revision or further imaging is required.

Correct Answer: Supine with one pillow under the head

The standard postmortem position is supine with one pillow under the head. This keeps the face elevated above the trunk, which prevents dependent pooling of blood from discoloring the face before the family viewing. Prone with the face turned is unusual in postmortem care and not standard for routine cases. The face becomes dependent under the body, which permits fluid drainage from the nose or mouth onto the bedding. Right side-lying with the head down places the face in a dependent position. Blood pools in the cheek and forehead pressed into the pillow, leaving discoloration visible to family members during their final viewing. High Fowler's positions the body in a sitting posture that is hard to maintain and uncomfortable for family viewing. The supine position with a single pillow is universally taught as the standard postmortem alignment.

Correct Answer: Sit upright and notify the nurse

These signs are autonomic dysreflexia, a hypertensive emergency in patients with spinal cord injury above T6. Sitting the patient upright lowers blood pressure, and the nurse must be notified immediately to identify and remove the trigger. Lowering the head of bed to flat keeps blood pressure high, which is the opposite of what the patient needs. Upright positioning takes advantage of gravity to lower blood pressure during the dysreflexia episode itself. Rechecking in fifteen minutes delays nurse notification of a hypertensive emergency that can cause stroke or seizure. Autonomic dysreflexia worsens quickly without intervention, and the trigger must be identified and removed in minutes. Cool washcloths and continued care do not address the underlying trigger, which is most often a full bladder or fecal impaction. The PCT must escalate so the trigger can be identified and removed promptly.