Basic Nursing Skills 11 Flashcards

A CNA is performing passive range-of-motion exercises on a resident's shoulder. The resident suddenly grimaces and says the pain level went from 2 to 7. What is the MOST appropriate immediate action?

Answer: Stop the exercise immediately and report the change in pain to the nurse

When a resident reports a significant increase in pain during ROM exercises, the CNA must stop immediately and report to the nurse. Continuing to exercise through acute pain can cause injury. The CNA must never push through a sudden pain escalation — this is a safety boundary. Applying compresses or delaying notification are inappropriate because they delay assessment of a potentially serious condition.

A CNA is assisting with a sterile dressing change and accidentally touches the sterile field with their ungloved hand. The nurse is momentarily out of the room. What should the CNA do?

Answer: Inform the nurse immediately upon their return that the sterile field has been contaminated

Once a sterile field is contaminated — even by brief, incidental contact — it is no longer sterile and the entire field must be considered compromised. The CNA must inform the nurse immediately so new sterile supplies can be prepared. Attempting to salvage part of the field, applying hand sanitizer, or proceeding are all violations of sterile technique that could cause serious infection.

When applying anti-embolism stockings (TED hose) to a resident, which finding would require the CNA to STOP and notify the nurse before continuing?

Answer: The CNA notices a reddened, warm area on the resident's calf before application

Redness, warmth, and localized swelling in the calf before applying TED hose are classic signs of a possible deep vein thrombosis (DVT). Applying compression stockings over a suspected DVT can dislodge the clot and cause a pulmonary embolism — a life-threatening emergency. The CNA must stop and notify the nurse immediately. Cool toes, a feeling of tightness, and minor sock indentation are expected findings that should still be monitored but do not require stopping.

A resident with a stage 3 pressure injury is being repositioned every 2 hours. The CNA notices that during repositioning, the resident's wound dressing has become saturated and partially lifted at one edge. What is the correct action?

Answer: Leave the dressing in place and report the findings to the nurse immediately

Wound care for stage 3 pressure injuries — including dressing changes — is outside the CNA's scope of practice unless specifically delegated and trained. The CNA's role is to observe and report findings to the nurse promptly. The nurse will assess and determine the appropriate dressing change. Reinforcing with tape, securing the edge, or performing the dressing change independently are all scope violations that could lead to wound infection or harm.

A CNA is measuring urinary output from a resident's indwelling catheter drainage bag. The bag contains 280 mL at the start of the shift. At the end of the 8-hour shift, the bag contains 430 mL, but the CNA also emptied 200 mL from the bag at hour 4. What is the total urinary output for the shift?

Answer: 630 mL

Total output = amount emptied mid-shift + amount remaining at end of shift minus the starting amount. The bag started at 280 mL, so the initial volume must be subtracted from the final reading. At hour 4, 200 mL was drained (bag reset to 0 effectively, but you calculate from the starting point). Correct calculation: (200 mL emptied at hour 4) + (430 mL final – 0 mL after midshift empty) = 630 mL. The starting 280 mL was already present before the shift and is not counted as output for this shift.

A CNA is caring for a resident using a mechanical lift for transfers. The sling was laundered by the laundry department and returned to the room. Before using it, the CNA should FIRST:

Answer: Inspect the sling for any tears, frayed edges, or damaged attachment loops before each use

Mechanical lift slings must be inspected before every use for structural integrity — including tears, fraying, stretched fabric, or damaged D-rings/loops — regardless of whether they were recently laundered. Laundering can weaken stitching or reveal pre-existing damage. Attempting to size-check by positioning first, testing on another resident, or waiting for nurse clearance are not standard pre-use protocols. Sling failure during a lift can cause a resident to fall and sustain serious injury.