Basic Nursing Skills 19 Flashcards

A resident with a stage II pressure injury on the coccyx is placed in the semi-Fowler's position for meals. After eating, the CNA should reposition the resident no later than how long after the initial positioning, and to which position, to minimize continued shear and pressure?

Answer: Tilt to a 30-degree lateral position within 30 minutes to offload the coccyx while maintaining comfort

A 30-degree lateral tilt (not full side-lying, which creates trochanter pressure) offloads the coccyx—the injured site—while reducing shear that semi-Fowler's creates as the body slides downward. Repositioning within 30 minutes limits continued ischemia to already-compromised tissue. Full supine returns pressure to the wound, and 90-degree elevation worsens shear.

While performing peri-care on a female resident with an indwelling urinary catheter, the CNA notices the catheter tubing has become kinked beneath the resident's thigh and urine has stopped draining for approximately 45 minutes. The drainage bag is less than half full. What is the correct sequence of immediate actions?

Answer: Straighten the kink to restore flow, assess for bladder distension by palpating the suprapubic area, then report to the nurse

The first step is correcting the mechanical obstruction (straightening the kink). After flow resumes, the CNA must assess for bladder distension—45 minutes of blockage in a catheterized resident can cause discomfort or autonomic dysreflexia in certain residents. Reporting to the nurse follows. Clamping is unnecessary and adds risk; irrigation and disconnection break the closed sterile system and require a nurse order.

A CNA is performing range-of-motion exercises on a resident recovering from a left-sided stroke with resulting right-sided hemiplegia. When moving the resident's right shoulder through circumduction, the resident suddenly grimaces and says 'that hurts.' What is the most appropriate immediate action?

Answer: Stop the movement immediately, hold the joint in a neutral supported position, and notify the nurse before continuing

Pain during ROM is never 'expected' and may indicate subluxation, rotator cuff injury, or heterotopic ossification—all common complications after stroke. The CNA must stop immediately, support the joint to prevent further injury, and report to the nurse before any further movement. Continuing, switching sides, or applying heat without assessment could worsen an undiagnosed injury.

A CNA is assigned to collect a clean-catch midstream urine specimen from a cognitively intact male resident who is ambulatory. The resident tells the CNA he already urinated into the specimen cup and hands it over—the cup contains approximately 120 mL of cloudy urine collected without cleansing or midstream technique. What should the CNA do?

Answer: Discard the specimen, explain the correct procedure to the resident, provide cleansing supplies, and have him collect a new specimen

A specimen collected without meatal cleansing and without the midstream void will be heavily contaminated with urethral flora, yielding unreliable results and potentially causing a misdiagnosis of UTI. The only correct action is to discard it, re-educate the resident, and collect a proper specimen. Relabeling, accepting, or diluting the sample are all professionally and clinically unacceptable.

During a bed bath, a CNA notices a small raised area of reddened skin over the right lateral malleolus (outer ankle bone) that does not blanch when pressed with a fingertip. The skin is intact. How should this finding be classified and what is the appropriate CNA action?

Answer: This is non-blanchable erythema consistent with a stage I pressure injury; stop the bath, reposition off the area, and report to the nurse before continuing

Non-blanchable erythema over a bony prominence with intact skin is the classic presentation of a stage I pressure injury. The CNA's role is to immediately offload the area, report the finding to the nurse for proper staging and care planning, and document observations—not to independently treat. Applying products without nurse direction exceeds scope; classifying it as a bruise or DTPI requires clinical assessment beyond CNA scope.

A CNA is assisting with the application of anti-embolic (TED) compression stockings on a resident who had hip replacement surgery three days ago. Upon removing the stockings for the mandatory skin check, the CNA observes that the resident's right calf is visibly larger than the left, warm to the touch, and the resident reports it feels 'tight and achy.' What should the CNA do?

Answer: Do not reapply the stockings, keep the resident calm and still, and report the findings to the nurse immediately

Unilateral calf swelling, warmth, and aching in a post-surgical patient are classic signs of deep vein thrombosis (DVT). Applying compression to a suspected DVT can dislodge the clot and cause pulmonary embolism—a life-threatening emergency. Massaging the calf is equally dangerous. The CNA must keep the resident still, withhold the stocking, and report immediately. This is an urgent situation requiring nurse and likely physician assessment.