Basic Care Flashcards

A practical nurse is caring for an 82-year-old client with moderate dementia who refuses to open their mouth for oral hygiene. The client becomes increasingly agitated when approached with a toothbrush. Which intervention is most appropriate?

Answer: Use a chlorhexidine swab during a moment of calm, timing the intervention with the client's natural mouth opening during speech or yawning

For clients with dementia who resist care, best practice involves using therapeutic timing — capitalizing on natural opportunities (speaking, yawning) — and using less threatening tools like swabs instead of toothbrushes. Chlorhexidine gluconate swabs reduce oral bacteria and aspiration pneumonia risk effectively. Deferring care increases risk of aspiration pneumonia, a leading cause of death in dementia. Sedation for routine hygiene is not ethically or clinically appropriate. Delegating entirely to family without nursing oversight is an abandonment of professional responsibility.

A practical nurse is repositioning a client who is post-op day 1 following a right hip replacement using the posterior approach. The client needs to be turned for skin assessment. Which position is contraindicated?

Answer: Right lateral (onto the operative side) with the hip in neutral rotation

Following posterior approach total hip replacement, turning the client onto the operative (right) side creates a risk of internal rotation and adduction of the hip — movements that can cause posterior dislocation. Even with pillows, this position is contraindicated in the early post-operative period. Turning to the non-operative left lateral side with the operative leg abducted and supported on pillows is the correct technique. Supine with pillow between knees and semi-Fowler's with heels offloaded are both acceptable positions that maintain hip precautions.

During a bath, a practical nurse notices a client's sacral area has an area of intact skin that appears purple/maroon in color and is firm and painful on palpation. There is no open wound. How should the nurse document and stage this finding?

Answer: Deep tissue pressure injury (DTPI), indicating probable deep soft tissue damage beneath intact skin

Purple or maroon discoloration of intact skin, particularly when firm, boggy, or painful, is the hallmark presentation of a Deep Tissue Pressure Injury (DTPI). This indicates damage to underlying muscle and soft tissue caused by intense and/or prolonged pressure, even though the overlying skin is intact. DTPI is a distinct category in the NPIAP/CPRISC staging system. Stage 1 is non-blanchable erythema (redness) of intact skin. Unstageable injuries have a covered wound base (slough or eschar). Stage 2 involves partial thickness skin loss. Misclassifying DTPI as Stage 1 is a critical documentation error as DTPI may rapidly deteriorate to a deep open wound.

A practical nurse is preparing to administer a cleansing enema to a 70-year-old client with cardiac history prior to a colonoscopy. The client reports feeling faint and the nurse notes the pulse is 48 bpm and irregular during the procedure. What is the priority action?

Answer: Stop the enema immediately, remove the rectal tube, place the client supine, and notify the physician

Bradycardia (48 bpm) with irregularity and presyncope during rectal stimulation indicates vasovagal response — a potentially life-threatening complication in a cardiac patient. The vagus nerve innervates the rectum; stimulation causes parasympathetic activation leading to bradycardia and hypotension. Priority actions are: (1) stop and remove the rectal tube to eliminate the vagal stimulus, (2) place the client supine to improve cerebral perfusion, and (3) notify the physician immediately. Leaving the tube in place (even while stopping flow) prolongs vagal stimulation. The left lateral Sims' position is used for enema administration, not emergency management of vasovagal response.

A practical nurse is caring for a client receiving enteral nutrition via nasogastric tube at 60 mL/hour. Before administering a medication, the nurse aspirates 280 mL of gastric residual volume (GRV). The client has no nausea, no abdominal distension, and bowel sounds are present in all quadrants. According to current evidence-based practice, what is the most appropriate action?

Answer: Return the aspirate to the client, continue the feeding at the current rate, and reassess GRV in 4 hours

Current evidence-based guidelines (ASPEN/SCCM) have moved away from routinely holding enteral feeding based solely on GRV thresholds. A GRV of 280 mL in the absence of clinical symptoms (no nausea, no vomiting, no abdominal distension, active bowel sounds) does not warrant stopping feeding. The aspirate should be returned to preserve electrolytes and digestive enzymes. Feeding should continue with close monitoring. Holding feeds based solely on GRV prolongs nutritional deficits without clear clinical benefit. Discarding the aspirate risks metabolic disturbances including hyponatremia and hypokalemia. Automatic physician notification is not required unless clinical signs of intolerance are present.

A practical nurse is performing a routine catheter care on a male client with an indwelling urinary catheter. Which action, if performed by a nursing student being supervised, would require immediate correction?

Answer: Positioning the drainage bag on the bed rail at the level of the client's bladder to facilitate drainage

The urinary drainage bag must always be kept below the level of the bladder to prevent backflow of urine into the bladder, which can introduce bacteria and cause a catheter-associated urinary tract infection (CAUTI). Placing the bag on the bed rail at bladder level — or above — creates a retrograde flow risk and must be corrected immediately. Cleansing the meatus using outward circular motion is correct technique. Securing the catheter to the inner thigh prevents urethral trauma from traction and is correct practice. Clean gloves are appropriate for catheter care (this is not a sterile procedure after insertion); sterile gloves are only required during catheter insertion.