Basic Nursing Skills 13 Flashcards

A CNA is measuring the blood pressure of a resident who has a left-sided AV fistula for dialysis. The right arm is currently in a cast. What is the most appropriate action?

Answer: Obtain thigh blood pressure using an appropriately sized cuff

A fistula arm must NEVER be used for blood pressure measurement because compression can damage the fistula, cause clotting, and compromise dialysis access. With the right arm in a cast, the thigh is the correct alternative site using a large cuff placed over the thigh and the stethoscope placed at the popliteal artery. Placing a cuff either proximal or distal to the fistula remains contraindicated.

While performing passive range-of-motion exercises on a resident's hip, the CNA notices the resident grimaces and moans but does not verbally complain. What is the priority action?

Answer: Stop the exercise, reposition the limb comfortably, and report the observation to the nurse

Nonverbal pain cues such as grimacing and moaning are valid pain indicators, especially in residents with cognitive or communication impairments. The CNA must stop the activity immediately to prevent injury, return the limb to a comfortable position, and report the findings to the nurse before continuing. Completing the sequence first risks worsening an injury; continuing more slowly still ignores the pain signal.

A resident with a stage II pressure injury on the sacrum is ordered to be repositioned every 2 hours. While preparing to reposition her from her right side to her back, the CNA notices the sheet beneath her is wrinkled. What should be done FIRST?

Answer: Smooth and tighten the sheet before completing the repositioning

Wrinkled sheets create shear and friction forces directly over bony prominences, which can worsen existing pressure injuries and cause new ones. The correct priority is to smooth and tighten the sheet BEFORE placing the resident onto it. Repositioning onto a wrinkled surface defeats the purpose of pressure relief. Barrier creams address moisture, not mechanical shear. A full linen change is not warranted and would delay repositioning unnecessarily.

A CNA is assisting a resident with a unilateral (left-sided) weakness to ambulate with a standard cane. Which technique reflects correct cane use?

Answer: Cane held in the right (stronger) hand, advanced simultaneously with the left (weaker) foot

A cane is always held in the stronger hand to offload weight from the weaker side. The cane is advanced at the same time as the weaker (opposite) foot — this mirrors normal gait where the contralateral arm swings forward with each step, providing a wider base of support and reducing load on the affected leg. Holding the cane in the weak hand provides no meaningful support to the affected extremity.

During a bed bath, the CNA notices a small, circular reddened area on the resident's left heel that does not blanch (turn white) when pressed. The skin is intact. How should this finding be classified and what is the immediate action?

Answer: Recognize it as a suspected deep tissue pressure injury and report it to the nurse immediately

Non-blanchable redness on intact skin over a bony prominence (heel) can indicate either a stage I pressure injury (superficial) or, when the redness appears as a deep purple/maroon discoloration or the tissue feels boggy or firm compared to adjacent tissue, a suspected deep tissue pressure injury (DTPI). A DTPI represents injury to underlying soft tissue despite intact skin and can rapidly deteriorate to a full-thickness wound. The priority is to immediately report the finding without applying heat (which increases metabolic demand) or dismissing it as normal variation.

A resident on Contact Precautions for C. difficile (C. diff) infection calls out that they need to use the bedpan urgently. The CNA's gloves are on but they have not yet put on their gown. What is the correct action?

Answer: Put on the gown before entering the room, even though it takes a brief additional moment

C. difficile spores are highly resilient and transmit via the fecal-oral route through contact with contaminated surfaces, including clothing. Contact Precautions require BOTH gloves AND gown before entering the room — no exceptions, even in urgent situations. C. diff spores are not killed by alcohol-based hand sanitizers, making strict PPE adherence critical. The few seconds needed to don the gown do not constitute patient abandonment and prevent potentially serious cross-contamination. Handing items through the door violates both dignity and safety.