Basic Nursing Skills 13 Flashcards

A CNA is measuring a resident's blood pressure and notices the Korotkoff sounds disappear briefly between systolic and diastolic readings before reappearing. The CNA should recognize this as:

Answer: An auscultatory gap, which may cause underestimation of systolic or overestimation of diastolic pressure

An auscultatory gap is a temporary disappearance of Korotkoff sounds during manual BP measurement, commonly seen in hypertensive patients. If unrecognized, it can lead to a falsely low systolic or falsely high diastolic reading. The CNA should inflate the cuff well above the point where sounds disappear and report the finding to the nurse.

A resident who has been on bed rest for three days is being assisted to stand for the first time. After standing for 30 seconds, the resident reports dizziness and the CNA notes a drop in systolic BP of 22 mmHg. The MOST appropriate next action is:

Answer: Have the resident sit or lie down immediately, then report the finding to the nurse before proceeding with ambulation

A systolic BP drop of 20 mmHg or more upon standing is the clinical definition of orthostatic hypotension. Continuing ambulation risks a fall and injury. The CNA must return the resident to a safe position, ensure safety, and report the objective finding (BP drop + symptoms) to the nurse before any further mobility attempts.

While providing perineal care to a female resident with an indwelling urinary catheter, the CNA should cleanse in which sequence?

Answer: Labia majora first, then labia minora, then from the urethral meatus distally along the catheter using a single downward stroke per wipe

Correct catheter perineal care begins with the labia majora (outer to inner), then the labia minora, and finally a single clean stroke from the meatus distally along the catheter tubing. This progression moves from less contaminated to most critical areas last, minimizing the risk of introducing microorganisms into the urinary tract. Back-to-front direction or reusing wipes introduces fecal flora near the urethra.

A CNA is performing passive range-of-motion (ROM) exercises on a resident with mild contracture of the left elbow. When the CNA reaches the point of resistance, the CORRECT action is:

Answer: Move the joint only to the point of resistance — do not force beyond it — and report increased resistance to the nurse

During passive ROM, a CNA must never force a joint past the point of resistance. Forcing movement can tear tendons, fracture weakened bones, or cause severe pain. The correct technique is to move to resistance, support the joint in that position, and stop. Any increase in resistance, pain, or change from the baseline range must be reported to the nurse for further evaluation.

A resident on a thickened-liquid diet (nectar consistency) requests a glass of regular water, stating they are very thirsty and 'tired of the thick stuff.' The CNA should:

Answer: Decline and explain that only the nurse or physician can modify the diet order, then report the resident's request to the nurse

A thickened-liquid diet is a physician-ordered aspiration precaution. CNAs do not have the authority to modify diet orders, even at a resident's request. Providing thin liquids could cause aspiration pneumonia. Ice chips are not universally safe — they melt into thin liquid. The correct action is to deny the modification, explain why kindly, and promptly report the request to the nurse so the team can reassess the order or provide education.

A CNA enters a resident's room and finds the resident unresponsive. After confirming unresponsiveness, the CNA shouts for help. Before leaving to activate the emergency response system, the CNA should FIRST:

Answer: Look for a posted DNR/POLST order in the room before initiating any emergency response

In a long-term care setting, a CNAs must check for a legally valid DNR (Do Not Resuscitate) or POLST/MOLST order before initiating CPR, as performing CPR on a resident with a valid DNR violates their legal advance directive and constitutes a scope violation. The DNR is typically posted at the bedside, on the chart, or above the bed. If no order is found, the CNA proceeds with emergency response per facility protocol. This is a critical distinction between acute-care and long-term care settings.