Basic Nursing Skills 13 Flashcards

A CNA is performing passive range-of-motion exercises on a resident's shoulder. The resident suddenly grimaces and says nothing, but the CNA notices resistance when abducting the arm past 90 degrees. What is the MOST appropriate immediate action?

Answer: Stop the movement at the point of resistance and report the finding to the nurse

When performing PROM exercises, CNAs must stop immediately at any point of pain, resistance, or grimacing — whichever comes first — and report to the nurse. Pushing through resistance can cause joint injury, muscle tears, or exacerbate an underlying condition. The nurse must assess before exercises resume.

While providing perineal care to a female resident with an indwelling urinary catheter, the CNA accidentally dislodges the catheter approximately 2 cm from the urethral meatus. The catheter is still draining urine into the bag. What should the CNA do?

Answer: Stop perineal care, do not reinsert or adjust the catheter, and notify the nurse immediately

CNAs must NEVER reinsert or manipulate a catheter that has been dislodged — this is outside their scope of practice and risks introducing pathogens into the urinary tract. Even though urine is still draining, the catheter's sterile field has been compromised and the nurse must be notified immediately to assess and intervene.

A resident on a mechanical soft diet begins coughing forcefully during a meal and can speak in a weak, wet-sounding voice between coughs. Which action is MOST appropriate for the CNA?

Answer: Stop feeding immediately, place the resident upright, remain with them, and alert the nurse now

A wet, gurgly voice during or after eating is a key aspiration warning sign — it indicates food or liquid may be pooling near the vocal cords. The resident can still speak, so the airway is not fully obstructed (ruling out Heimlich). The CNA must stop the meal, ensure upright positioning to reduce aspiration risk, and notify the nurse immediately rather than waiting 2 minutes.

A CNA is measuring a non-ambulatory resident's blood pressure. The first reading on the right arm is 158/96 mmHg. The care plan does not specify a preferred arm. What is the MOST clinically sound next step before reporting this value?

Answer: Wait 1–2 minutes, retake on the same arm, and if still elevated report both readings to the nurse

Best practice for an unexpectedly elevated BP reading is to allow 1–2 minutes of rest (to clear transient elevation from cuff pressure or anxiety), retake on the same arm for consistency, and report both readings if still elevated. Switching arms without direction changes the reference point. Reporting a single reading is insufficient for clinical decision-making; waiting 5 full minutes is unnecessarily long in a potentially urgent situation.

A resident with a stage 2 pressure injury on the coccyx is placed on an alternating pressure mattress. The CNA notices that when repositioning the resident every 2 hours, the wound dressing is consistently intact and the area shows no drainage. The resident asks why they must still be turned so frequently if the mattress is 'doing the job.' What is the BEST response?

Answer: 'The mattress reduces pressure between bony areas but does not eliminate it entirely; repositioning is still required to protect the wound and surrounding skin.'

Pressure-redistributing devices (including alternating pressure mattresses) are adjuncts to — not replacements for — manual repositioning. They reduce peak interface pressure but cannot fully eliminate it over bony prominences for extended periods. The existing stage 2 injury means the skin is already compromised and especially vulnerable; repositioning every 2 hours remains the standard of care. Options A and D suggest altering the care plan, which is outside CNA scope.

During a bed bath, a CNA removes a resident's gown and observes a 4 cm area of dark purple, non-blanchable discoloration over the left greater trochanter with intact skin and a slightly boggy texture on palpation. The resident denies pain in that area. How should the CNA classify and respond to this finding?

Answer: This is consistent with a deep tissue pressure injury; stop the bath, cover the area, and report to the nurse before continuing care

The combination of dark purple/maroon non-blanchable discoloration with intact skin and boggy texture over a bony prominence (greater trochanter) is the classic presentation of a suspected Deep Tissue Pressure Injury (DTPI). This is a serious finding requiring immediate nurse notification — not end-of-shift — because the underlying tissue may already be extensively damaged despite intact skin. CNAs should never apply dressings or classify wounds; they report and document.