Basic Nursing Skills 14 Flashcards

A CNA is performing passive range-of-motion exercises on a resident's shoulder when the resident suddenly grimaces and says nothing but grips the bedrail. What is the MOST appropriate immediate action?

Answer: Stop the exercise immediately and report the nonverbal pain response to the nurse

Nonverbal cues such as grimacing and gripping the bedrail are valid indicators of pain, especially in residents who may not verbalize discomfort. The CNA must stop immediately, as continuing could cause injury. Reporting to the nurse ensures a proper assessment and adjustment to the care plan.

When applying antiembolism (TED) stockings to a resident, which finding should cause the CNA to withhold application and notify the nurse BEFORE proceeding?

Answer: One lower leg has a red, warm, and visibly swollen area compared to the other

Unilateral redness, warmth, and swelling in a lower extremity are classic signs of a possible deep vein thrombosis (DVT). Applying compression stockings over a suspected DVT can dislodge the clot and cause a pulmonary embolism. This must be reported immediately and stockings withheld until a nurse evaluates the resident.

A resident on droplet precautions is being transported via wheelchair to radiology. Which combination of PPE is CORRECT for the CNA performing the transport?

Answer: Surgical mask only

Droplet precautions require a surgical mask when within 3 feet of the resident — not an N95 (which is for airborne precautions), and not necessarily gloves or a gown unless there is anticipated contact with secretions. The resident should also be masked if tolerated during transport to contain droplets.

A resident with a nasogastric tube in place requires oral care. Which action is MOST important during this procedure?

Answer: Perform oral care with the head of bed elevated at least 30 degrees and use only small amounts of fluid

Residents with NG tubes are at high aspiration risk because the tube itself can impair the normal gag reflex and esophageal sphincter function. The head of bed must be elevated at least 30 degrees during oral care to reduce aspiration risk, and only small amounts of fluid or moistened swabs should be used to prevent fluid from being aspirated into the lungs.

During perineal care on a female resident who is incontinent of stool, the CNA notices a small amount of bright red bleeding from the vaginal area. What should the CNA do?

Answer: Stop the procedure, cover the resident, and immediately report the finding to the nurse

Unexpected vaginal bleeding is an abnormal finding that requires immediate reporting to the nurse — it is outside the CNA's scope to assess the cause. The procedure should be stopped to avoid disturbing the area further, the resident should be covered to preserve dignity, and the nurse must evaluate promptly as this could indicate a serious condition.

A CNA is repositioning a comatose resident and notices the resident's sacral area has intact skin but a persistent, non-blanchable area of redness that does not fade after 30 minutes off-pressure. How should this be classified and handled?

Answer: This is a Stage 1 pressure injury — the CNA should document, report to the nurse, and ensure turning schedule is maintained

Non-blanchable erythema on intact skin that persists after pressure is relieved is the defining characteristic of a Stage 1 pressure injury. The CNA must report this to the nurse for care plan updates and document the finding. Maintaining the repositioning schedule (at least every 2 hours) is critical. Stage 2 involves broken or blistered skin; deep tissue injury presents with purple or maroon discoloration.