CPNRE Basic Care 2 — Questions and Answers

Question 1: A practical nurse performs a head-to-toe assessment on a newly admitted client. Which finding requires immediate follow-up?

Blood pressure 118/76 mmHg
Oxygen saturation of 88% on room air (Correct answer)
Temperature 37.2 degrees Celsius
Respiratory rate of 16 breaths per minute

Correct answer: Oxygen saturation of 88% on room air

SpO2 of 88% is below normal (95-100%) and indicates hypoxemia requiring immediate intervention.

SpO2 88% indicates significant hypoxemia requiring immediate supplemental oxygen, positioning, and physician notification. The other values are within normal limits. In Canadian nursing practice, nurses must recognize and respond immediately to signs of respiratory compromise.

Question 2: When providing perineal care for a female client, what is the correct technique?

Wipe from back to front
Wipe from front to back using a clean cloth section for each stroke (Correct answer)
Use the same cloth section throughout
Begin from the anal area toward the urethra

Correct answer: Wipe from front to back using a clean cloth section for each stroke

Front to back wiping prevents fecal bacteria from reaching the urethra, reducing UTI risk.

Perineal care proceeds from urethra to anus (front to back) to prevent introducing E. coli and other fecal organisms into the urinary tract. Each stroke uses a clean cloth section. This principle is consistent with IPAC Canada guidelines and applies in all Canadian provinces.

Question 3: At what angle is semi-Fowlers position maintained?

10-20 degrees
30-45 degrees (Correct answer)
60-90 degrees
15-25 degrees

Correct answer: 30-45 degrees

Semi-Fowlers is 30-45 degrees, used for respiratory issues, tube feedings, and post-cardiac procedures.

Semi-Fowlers (30-45 degrees) facilitates diaphragm descent for breathing, reduces aspiration risk during tube feedings, and is standard post-cardiac catheterization positioning. Full Fowlers is 60-90 degrees. Low Fowlers is 15-30 degrees. Practical nurses must know correct positioning terminology per Canadian nursing standards.

Question 4: During a bed bath, which area should be washed last?

Face and neck
Arms and hands
Perineal area and buttocks (Correct answer)
Legs and feet

Correct answer: Perineal area and buttocks

The perineum is washed last as it has the highest microbial load, preventing cross-contamination.

Standard bed bath sequence: face, neck, arms, trunk, legs, feet, then perineal area/buttocks. Washing the perineum last prevents spreading fecal bacteria to other areas. A fresh washcloth is used for the perineal area. Gloves are worn throughout. This is consistent with IPAC Canada infection prevention principles.

Question 5: When providing oral hygiene to an unconscious client, which action has the highest priority?

Brush teeth vigorously
Position supine to facilitate rinsing
Position in lateral position with head turned to the side (Correct answer)
Use full-strength hydrogen peroxide

Correct answer: Position in lateral position with head turned to the side

Lateral positioning with head turned to the side prevents aspiration of fluids during oral care.

For unconscious clients, lateral positioning with the head turned to the side allows fluids to drain from the mouth rather than pooling in the posterior pharynx and being aspirated. Small amounts of solution should be used, and suction must be available. This prevents aspiration pneumonia, a serious complication managed per Canadian nursing practice standards.

Question 6: What is the primary purpose of using a draw sheet when repositioning a client in bed?

Keeping the client warm
Reducing friction and shear forces on the skin (Correct answer)
Restraining the client
Absorbing moisture

Correct answer: Reducing friction and shear forces on the skin

A draw sheet reduces friction and shear that cause skin breakdown and pressure injuries.

A draw sheet reduces friction (skin rubbing surfaces) and shear (tissue layers sliding against each other) during repositioning. Both forces damage skin and underlying tissue, contributing to pressure injuries. Using a draw sheet allows sliding rather than dragging, protecting skin integrity. Pressure injury prevention is a significant patient safety priority identified by Accreditation Canada.

CPNRE Basic Care 2

A practical nurse performs a head-to-toe assessment on a newly admitted client.
Which finding requires immediate follow-up?