Basic Nursing Skills 11 Flashcards

A CNA is performing passive range-of-motion exercises on a resident's shoulder. The resident suddenly winces and says 'that hurts.' What is the most appropriate immediate action?

Answer: Stop the movement at the point of pain and report to the nurse

ROM exercises should never be forced through pain. The CNA must stop immediately at the point of pain to prevent injury, then report the finding to the nurse. Pain during ROM can indicate injury, inflammation, or joint pathology that requires clinical assessment.

When measuring urinary output for a resident on strict I&O, the CNA notices the urine appears dark amber and has a strong odor. Output is 180 mL over 8 hours. Which action is MOST appropriate?

Answer: Record the output and note the color and odor on the I&O sheet, then report findings to the nurse

A CNA must document objective observations — including output volume, color, and odor — and report abnormal findings to the nurse promptly. Dark amber urine with strong odor and low output (normal is ~30 mL/hr minimum) suggests possible dehydration or infection requiring nursing assessment. CNAs must report, not independently intervene by altering fluid intake.

A resident with a Stage 2 pressure injury on the coccyx is being repositioned. The CNA notices the dressing is partially lifted and the wound edges appear slightly macerated. What should the CNA do?

Answer: Reposition the resident and immediately report the dressing status and wound appearance to the nurse

Wound assessment and dressing changes are outside CNA scope of practice. The CNA's responsibility is to observe, report, and reposition safely. Smoothing a contaminated dressing could introduce infection; removing and replacing a dressing requires a nurse's order and sterile/clean technique. Maceration (skin softening from moisture) is a clinically significant finding the nurse must evaluate.

A CNA is assisting a resident who uses a mechanical lift (Hoyer) for transfers. Midway through the transfer, the resident begins to slide in the sling and expresses fear. What is the CORRECT response?

Answer: Lower the resident back to the bed immediately and call for assistance before reattempting

A sliding or improperly positioned resident in a mechanical lift presents a serious fall and injury risk. The safe action is to reverse the process and lower the resident back to the surface, then reposition the sling correctly with assistance before reattempting. Completing the transfer quickly while the resident is unstable, having the resident hold straps (which shifts weight unpredictably), or manually tilting the boom are all unsafe practices that risk dropping the resident.

A cognitively intact resident refuses to have their blood pressure taken, stating they 'don't want to be bothered today.' The nurse has ordered vital signs every 4 hours due to a new medication. How should the CNA proceed?

Answer: Respect the refusal, document that the resident declined, and report the refusal to the nurse immediately

Competent adults have the legal and ethical right to refuse care, including vital sign assessment. The CNA must respect this right, document the refusal accurately, and report to the nurse immediately — especially given the clinical context of a new medication requiring monitoring. Waiting silently, taking readings without consent, or using family to override a competent refusal are all violations of resident rights and/or patient consent principles.

During perineal care for a female resident with an indwelling urinary catheter, the CNA notices the catheter tubing is kinked and the drainage bag has had no output for the past 2 hours. The bag is positioned below the bladder. What is the PRIORITY action?

Answer: Unkink the tubing to restore drainage and report the 2-hour output gap to the nurse

A kinked catheter is a mechanical obstruction the CNA can safely correct — removing the kink is within scope. However, 2 hours of zero output is abnormal and may indicate a blockage beyond the kink, bladder spasm, or dislodgement, which requires nursing assessment. Repositioning the bag higher would cause reflux of urine back into the bladder (infection risk). Irrigation is a nursing/advanced skill. Completing care without reporting the output gap omits critical clinical information.