Basic Care Flashcards

A practical nurse is caring for an 82-year-old client with moderate dementia who repeatedly removes their urinary catheter. The client is agitated and cannot follow redirection. Which intervention should the nurse implement FIRST?

Answer: Perform a thorough assessment to identify the underlying cause of the agitation

Assessment must always precede intervention. The agitation causing catheter removal may have a treatable cause such as catheter obstruction, UTI, pain, urinary retention, or constipation. Identifying and resolving the root cause is the priority. Restraints and anxiolytics carry significant risks in elderly clients with dementia and are not first-line responses. A sitter may be appropriate after assessment but does not address the underlying problem.

A client on a medical unit has a stage II pressure injury on the sacrum with a moist wound base and intact surrounding skin. The wound care order reads 'hydrocolloid dressing, change every 3 days.' On day 2, the nurse observes a yellow-brown fluid-filled blister under the dressing. What is the correct interpretation and action?

Answer: This is a normal appearance of a hydrocolloid dressing interacting with wound exudate; continue per the scheduled change

Hydrocolloid dressings interact with wound exudate to form a characteristic yellow-brown, gel-like blister beneath the dressing. This is an expected and normal occurrence — it does not indicate infection, wound deterioration, or a sinus tract. The dressing should be changed on schedule (day 3) unless it is leaking, displaced, or there are other clinical signs of infection such as periwound erythema, warmth, odor, or systemic symptoms. Premature removal disrupts the healing environment.

A practical nurse is preparing to insert a nasogastric (NG) tube for gastric decompression in a post-operative adult client. After inserting the tube to the measured length, the nurse attempts to confirm placement. Which combination of confirmation methods meets current best-practice standards in Canada?

Answer: pH testing of aspirated gastric contents (pH ≤ 5.5) and radiographic confirmation

Current Canadian and international best-practice guidelines (including those from the Canadian Patient Safety Institute) identify pH testing of aspirated content (pH ≤ 5.5 confirms gastric placement) combined with radiographic (X-ray) confirmation as the gold standard for initial NG tube placement verification, particularly for high-risk uses such as decompression or feeding. Auscultation of air insufflation ('whoosh' test) is unreliable and no longer recommended as a sole or primary method. The water submersion test and capnography are not validated for NG confirmation.

A client with heart failure is prescribed a fluid restriction of 1,200 mL per 24 hours. At 1400h, the intake record shows: morning medications with 180 mL water, breakfast juice 120 mL, IV piggyback antibiotics in 100 mL NS (completed at 1200h), lunch soup 150 mL, and oral intake of 240 mL since lunch. How many millilitres remain for the rest of the shift and night?

Answer: 410 mL

Total intake so far: 180 (medications) + 120 (juice) + 100 (IV piggyback) + 150 (soup) + 240 (oral since lunch) = 790 mL. Remaining: 1,200 − 790 = 410 mL. IV piggyback fluid counts toward fluid intake in clients with restrictions. Errors in fluid restriction management are a common cause of fluid overload and hospital readmission in heart failure clients, making meticulous inclusion of all fluid sources essential.

A practical nurse is providing oral care to an unconscious client receiving mechanical ventilation via an endotracheal tube. Which action poses the GREATEST risk of aspiration pneumonia in this client?

Answer: Using excessive amounts of liquid and relying only on a Yankauer suction catheter for removal

Using excessive liquid during oral care of an unconscious, intubated client creates a significant pooling risk in the oropharynx. Even with a cuffed ETT, micro-aspiration can occur around the cuff if large fluid volumes accumulate and are not fully suctioned. Best practice specifies using minimal liquid, applying suction concurrently, and using specialized oral care kits designed for ventilated patients. Chlorhexidine 0.12% is evidence-based for VAP prevention. Head of bed elevation at 30–45° is a core VAP bundle measure. Toothbrushing is recommended.

During a routine skin assessment of an elderly client with dark skin tone, the practical nurse is evaluating for early-stage pressure injury. Which assessment finding is MOST reliable for detecting Stage I pressure injury in a client with deeply pigmented skin?

Answer: Localized area that is warmer, firmer, or softer than surrounding tissue with the client reporting pain or discomfort

In clients with dark or deeply pigmented skin, erythema (redness) may not be visible — this is a well-documented limitation of visual assessment. Stage I pressure injuries in these clients are best identified through tactile and subjective assessment: changes in tissue temperature (warmth from inflammation or coolness from ischemia), changes in tissue consistency (edema, firmness, or boggy softness compared to adjacent tissue), and client-reported pain, itching, or discomfort. This is a critical competency in preventing underdiagnosis of pressure injuries in clients with darker skin tones.