Basic Nursing Skills 15 Flashcards

A CNA is caring for a patient with a stage 2 pressure injury on the coccyx. When repositioning the patient, the CNA notices the wound dressing has become saturated. Which action should the CNA take first?

Answer: Report the saturated dressing to the nurse immediately before repositioning

A saturated wound dressing on a stage 2 pressure injury requires immediate nursing assessment before any repositioning or dressing changes occur. CNAs are not permitted to perform wound care or change wound dressings independently. Notifying the nurse first ensures proper wound management and repositioning instructions are given. Completing the repositioning first could further damage the wound, and documenting without reporting delays necessary care.

While performing morning care, a CNA notices a patient's urine in the catheter drainage bag is dark amber, cloudy, and has a strong odor. The patient's last recorded output was 8 hours ago. Which finding is MOST clinically significant and should be reported to the nurse immediately?

Answer: The combination of dark amber color, cloudiness, and strong odor together

The combination of dark amber color (concentrated or blood-tinged urine), cloudiness (possible infection or sediment), and strong odor together represents multiple simultaneous abnormalities that collectively signal a potential urinary tract infection or other serious complication. No single finding in isolation is as significant as all three together. While the 8-hour documentation gap is concerning, the cluster of abnormal urine characteristics is the most immediately clinically significant finding requiring urgent reporting.

A CNA is assisting a post-surgical patient with ambulation using a gait belt. After taking three steps, the patient says, 'I feel dizzy and my legs feel weak.' What is the CORRECT sequence of actions?

Answer: Ease the patient to the floor in a controlled descent, call for help, and stay with the patient

When a patient reports dizziness and leg weakness during ambulation and a fall appears imminent, the safest action is a controlled lowering to the floor. This protects both the patient and the CNA from injury better than attempting to reach a chair, which may be too far away. Calling for help after lowering ensures the patient is not left alone. Encouraging continued walking ignores a safety emergency, and leaving the patient standing alone risks an uncontrolled fall.

A CNA is assigned to a patient on Contact Precautions for C. difficile (C. diff). The CNA finishes care and performs hand hygiene using the alcohol-based hand sanitizer dispenser outside the room. This action is:

Answer: Incorrect, because soap and water must be used after caring for a patient with C. difficile

C. difficile spores are resistant to alcohol-based hand sanitizers. Soap and water friction is required to physically remove C. diff spores from the hands — alcohol does not kill them. This is a critical exception to the general guideline favoring alcohol-based sanitizers. Gloves alone are never a substitute for hand hygiene; hands must always be cleaned after glove removal, and for C. diff specifically, that means soap and water.

A CNA is feeding an elderly patient who has dysphagia and is on a pureed diet with nectar-thick liquids. The patient insists on drinking thin water from a cup on the tray. The CNA should:

Answer: Remove the thin water and explain that the patient must follow the prescribed thickened liquid diet to prevent aspiration

A prescribed dysphagia diet, including liquid consistency modifications, is a medical order designed to prevent aspiration pneumonia — a life-threatening complication. The CNA must remove the non-compliant item and explain why the restriction exists. Allowing thin liquids could cause aspiration; adding thickener at bedside without nursing oversight is outside the CNA's scope; and while patient autonomy is important, unilaterally documenting diet refusal without first redirecting the patient and notifying the nurse is inadequate and unsafe.

A CNA performing passive range-of-motion (PROM) exercises on a patient's right arm notices that the patient grimaces and the elbow joint feels stiff and resistant at approximately 90 degrees of flexion. The CNA should:

Answer: Stop the exercise at the point of resistance, note the limitation, and report to the nurse

PROM should never be forced past the point of resistance or pain. A grimace is a non-verbal pain indicator that must be respected even if the patient cannot or does not vocalize. Stopping at the resistance point, noting the joint limitation and pain response, and reporting to the nurse ensures the care team can assess for conditions like contracture, joint inflammation, or injury before exercises are continued. Forcing past resistance can cause fractures, dislocations, or tissue damage. Non-verbal pain cues (grimacing) carry the same weight as verbal complaints.