Basic Nursing Skills 18 Flashcards

A CNA is performing passive range-of-motion exercises on a resident's shoulder. The resident suddenly grimaces and says 'that hurts a little, but keep going.' What is the correct action?

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

Any report of pain during ROM exercises requires the CNA to stop immediately. Pain indicates the joint or tissue may be stressed beyond its safe limit. The resident's verbal consent to continue does not override the clinical obligation to stop and report — pain during ROM is a reportable change in condition, not a normal finding to push through.

When measuring urinary output from an indwelling catheter drainage bag, which technique error would cause a falsely HIGH reading?

Answer: Reading the graduated cylinder at eye level from above rather than at the meniscus

Reading a graduated cylinder from above rather than at eye level at the meniscus causes parallax error, making the fluid level appear higher than it actually is, resulting in a falsely elevated urine output recording. Accurate measurement requires the cylinder to be on a flat surface and read at eye level at the bottom of the meniscus curve.

A resident on a mechanical soft diet is found to have pocketed food in the right cheek after a meal. When the CNA reports this to the nurse, what underlying condition does this behavior most strongly suggest should be evaluated?

Answer: Unilateral facial muscle weakness or decreased oral sensation on that side

Pocketing food consistently in one cheek is a classic sign of unilateral weakness or sensory loss — often from a stroke affecting one side of the face or mouth. The resident cannot feel or move food on the affected side, so it accumulates. This is a significant aspiration and choking risk that warrants prompt nursing and possibly speech therapy evaluation. It is not simply a behavioral or preference issue.

A CNA is applying antiembolism stockings (TED hose) to a bedridden resident at 8:00 AM. The resident's legs were elevated for 30 minutes prior. What is the MOST important assessment finding that should cause the CNA to withhold the stockings and notify the nurse before applying them?

Answer: One calf is visibly larger than the other and warm to the touch

Unilateral calf swelling with warmth is a classic presentation of deep vein thrombosis (DVT). Applying compression stockings over a suspected DVT can dislodge a thrombus, potentially causing a life-threatening pulmonary embolism. This finding must be reported immediately and the stockings withheld until a nurse or physician evaluates the resident. Dry skin and toenail changes are chronic findings that should be documented but do not contraindicate stocking application.

During a bed bath, a CNA notices a stage 2 pressure injury on the resident's coccyx that was not documented in the care plan. After covering the area and ensuring the resident's comfort, what is the CNA's correct sequence of next steps?

Answer: Report the finding to the charge nurse immediately before completing the bath, then document the observation per facility policy

A newly identified pressure injury is an immediate reportable finding — the CNA must notify the charge nurse before continuing non-urgent care tasks. Delaying until the bath is complete or until shift huddle allows more time without proper wound assessment and treatment orders. CNAs do not independently apply wound treatments (including moisture barrier over open skin) without a nurse assessment and order. Documentation follows the verbal report and must occur per facility policy, not at the end of shift.

A CNA is assisting a resident with a transfer from bed to wheelchair using a gait belt. The resident begins to feel faint mid-transfer and her knees start to buckle. Which action BEST protects both the resident and the CNA?

Answer: Widen your stance, bend your knees, and guide the resident into a controlled lowering to the floor

When a resident begins to fall mid-transfer, the priority is a controlled descent to the floor — not trying to hold them upright or pivot them back. Attempting to hold a collapsing resident upright risks injury to both the resident (from sudden catching forces) and the CNA (back/shoulder injury). Widening the stance, bending the knees, and guiding them to the floor using the gait belt and body weight distributes the load safely and prevents an uncontrolled fall. Calling for help while struggling to hold them upright is secondary and does not address the immediate physical threat.