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 agitated and bites down on the toothbrush. Which intervention is most appropriate?

Answer: Offer a flavoured foam swab and approach during a calm period, using a step-by-step verbal cue

For clients with dementia who resist oral care, the evidence-based approach is to use distraction (flavoured swabs are less threatening than a toothbrush), time interventions during the client's calmest period of day, and use simple step-by-step verbal or visual cues. Deferring care leads to oral health deterioration and increased aspiration risk. Mouth props without consent are restraints and violate dignity. Sedation is not warranted for routine care resistance.

A PN is performing perineal care on a female client who has an indwelling urinary catheter. After cleansing the perineum, what is the correct next step specific to catheter care?

Answer: Clean the catheter from the meatus outward at least 10 cm using a single downward stroke, then discard the cloth

The correct technique for catheter care is to clean from the meatus outward (away from the body) for at least 10 cm using a single unidirectional stroke with each wipe to prevent introducing microorganisms toward the urinary tract. Circular motion risks recontamination. Disconnecting the catheter-tubing junction breaks a closed system and dramatically increases CAUTI risk. Routine antiseptic application at the meatus is not recommended by current evidence and can irritate tissue.

A PN is repositioning a semi-conscious bariatric client (weight 210 kg) who is at high risk for pressure injuries. The care team has a lateral transfer device available. Which position change schedule and pressure redistribution strategy best reflects current best practice?

Answer: Reposition every 2 hours using a 30-degree lateral tilt; use a high-specification reactive foam or alternating pressure mattress

Current NPUAP/EPUAP guidelines recommend repositioning every 2 hours (or more frequently for high-risk clients) using a 30-degree lateral tilt rather than a full 90-degree position, because the 30-degree tilt avoids direct pressure over the greater trochanter — a common breakdown site. Bariatric clients require a high-specification reactive foam or alternating-pressure mattress to redistribute weight effectively; standard mattresses bottom out. A 4-hour schedule is insufficient for high-risk clients.

During a bed bath, the PN notices a 2 cm × 1.5 cm area of intact skin over the sacrum that is non-blanchable, dark red, and warm to the touch compared with surrounding tissue. The client has been on bed rest for 3 days. How should this finding be classified and what is the priority action?

Answer: Suspected deep tissue pressure injury (DTPI); photograph, document, notify the most responsible provider, and offload the area

Non-blanchable discolouration that is dark (purple/maroon/dark red) with warmth over a bony prominence after sustained pressure is classified as a Suspected Deep Tissue Pressure Injury (DTPI). Unlike a Stage 1 (which is pink/red and represents superficial changes), DTPI signals deeper tissue destruction that may rapidly evolve to a full-thickness wound. Priority actions are accurate documentation (including photography), immediate offloading of the area, and notification of the most responsible provider so a wound specialist can be involved. A transparent film alone is insufficient management for a DTPI.

A PN is assisting a client with dysphagia (IDDSI Level 4 — Puréed) with meals. The client suddenly becomes silent, stops chewing, and has a look of panic. Attempts to cough are weak and inaudible. Which action should the PN take FIRST?

Answer: Perform 5 back blows followed by 5 abdominal thrusts (Heimlich manoeuvre)

Silent coughing or an absent cough in a choking client indicates severe airway obstruction — the 'silent choke.' The Canadian Red Cross and Heart & Stroke Foundation protocols call for 5 back blows followed by 5 abdominal thrusts (Heimlich) for a conscious adult with complete airway obstruction. CPR is only initiated if the person becomes unresponsive. Oxygen does not relieve a mechanical obstruction. Suctioning a Yankauer may be an adjunct but is not the first-line response for solid food obstruction and wastes critical time.

A PN is caring for a client receiving continuous enteral nutrition via a nasogastric tube. The client's gastric residual volume (GRV) is 320 mL when checked before medication administration. The facility protocol states to hold feeds for GRV > 250 mL and recheck in 1 hour. Which additional assessment finding would most indicate the need to halt the feed AND notify the provider urgently, rather than simply rechecking in 1 hour?

Answer: The client has new abdominal distension, absent bowel sounds in all four quadrants, and a rigid abdomen

While an elevated GRV warrants a recheck per protocol, the combination of new abdominal distension, absent bowel sounds in all four quadrants, and rigidity are signs of possible paralytic ileus or bowel obstruction — a potentially life-threatening situation requiring immediate provider notification and cessation of enteral feeding. Mild nausea at 2/10 and 36-hour constipation are concerning but do not carry the same urgency as peritoneal signs. A blood glucose of 9.8 mmol/L is slightly elevated but common in enterally-fed clients and managed per glycaemic protocol, not an urgent indicator to stop feeds.