Basic Care and Comfort: Practice Questions & Explanations

RANGE-OF-MOTION EXERCISES maintain joint flexibility, prevent contractures, maintain muscle tone, improve circulation, and prevent complications of immobility. TYPES: PASSIVE ROM — nurse moves the client's joints through the range; used when client cannot participate (unconscious, complete paralysis, very weak); ACTIVE-ASSISTED ROM — nurse assists the client who can do some movement; ACTIVE ROM — client performs exercises independently; nurse provides instruction and encouragement. CORRECT TECHNIQUE: SUPPORT: hold the limb at the joint (above AND below) to stabilize and support the weight; SMOOTH AND SLOW: no jerky or rapid movements; FULL AVAILABLE RANGE: move the joint as far as it will comfortably go; STOP FOR PAIN: pain indicates possible injury or joint problem; stop, document, and report; WARMTH helps muscles and joints move more freely; some facilities encourage warm soaks prior to ROM; SEQUENCE: start at head and work down, or from proximal (closer to body) to distal (farther from body). FREQUENCY: typically 2-4 times per day; each joint 5-10 repetitions. ROM MOVEMENTS by joint type: HINGE JOINTS (elbow, knee) — flexion and extension; BALL-AND-SOCKET (shoulder, hip) — flexion, extension, abduction, adduction, rotation, circumduction; PIVOT (neck) — rotation; SADDLE (thumb) — wide variety of movements. CONTRACTURES: fixed joint deformity from muscle shortening due to prolonged immobility; prevention is key — far harder to reverse than to prevent; foot drop (plantar flexion contracture) prevented with foot board or splints and dorsiflexion ROM. PN ROLE: perform passive ROM, active-assisted ROM; document tolerance; report any pain, redness, swelling, decreased range; reinforce PT/OT instructions; educate family on ROM techniques.

PRESSURE INJURIES (formerly called pressure ulcers or decubitus ulcers) are localized areas of injury to the skin and/or underlying tissue, usually over a bony prominence, resulting from sustained pressure, shear, or friction. PATHOPHYSIOLOGY: pressure compresses capillaries, reducing blood flow; ischemia leads to tissue death; prolonged pressure (even low pressure over time) causes injury; highest-risk areas: sacrum/coccyx, heels, greater trochanter, ischial tuberosities, occiput, medial and lateral malleoli, elbows, scapulae. STAGING (NPUAP/EPUAP): STAGE 1: non-blanchable erythema of intact skin — early warning sign; STAGE 2: partial-thickness skin loss, shallow open ulcer with red/pink wound bed; STAGE 3: full-thickness skin loss, subcutaneous fat visible; STAGE 4: full-thickness tissue loss, bone, tendon, or muscle visible; UNSTAGEABLE: full-thickness but covered by slough/eschar; DEEP TISSUE INJURY: intact skin with discoloration/blood-filled blister. PRIMARY INTERVENTIONS: REPOSITIONING every 2 hours (or per individualized schedule based on tissue tolerance and patient condition); documentation of position changes; SKIN INSPECTION with each repositioning (especially bony prominences); KEEP SKIN CLEAN AND DRY: moisture (incontinence, sweat) dramatically increases skin breakdown; use moisture barriers (zinc oxide); MINIMIZE FRICTION AND SHEAR: use lift sheets for repositioning, not dragging; PRESSURE REDISTRIBUTION: specialty mattresses (foam, air-fluidized, low-air-loss); heel protectors; NUTRITION AND HYDRATION: protein critical for tissue repair (target adequate protein intake); adequate fluids; nutritional supplements if needed; BRADEN SCALE: most common standardized risk assessment tool (scores sensory perception, moisture, activity, mobility, nutrition, friction/shear; score ≤18 indicates risk).

CATHETER-ASSOCIATED URINARY TRACT INFECTION (CAUTI) is the most common healthcare-associated infection (HAI) in hospitals. Every day an indwelling urinary catheter is in place increases infection risk by 3-7%. CAUTI PREVENTION is a major patient safety priority. APPROPRIATE INDICATIONS FOR INDWELLING URINARY CATHETERS: urinary retention that doesn't respond to other management; accurate I&O monitoring in critically ill clients; perioperative use for specific surgeries; wound healing in sacral/perineal wounds where urine would compromise healing; hospice/end-of-life comfort; urological procedures; neurogenic bladder (selected cases). NOT APPROPRIATE indications: incontinence for CONVENIENCE (of staff or client); prolonged post-operative use without clinical need; avoiding repositioning. ALTERNATIVES TO CATHETERIZATION FOR INCONTINENCE: SCHEDULED TOILETING (every 2-4 hours); PROMPTED VOIDING; BLADDER TRAINING; EXTERNAL CONDOM CATHETER (for male patients); ABSORBENT PADS/BRIEFS; SKIN PROTECTION (moisture barriers to prevent skin breakdown from moisture — valid concern but doesn't require catheter); PELVIC FLOOR EXERCISES (Kegel exercises, though less applicable in acute illness). IF CATHETER IS GENUINELY INDICATED: use SMALLEST POSSIBLE CATHETER (less trauma); maintain CLOSED STERILE DRAINAGE SYSTEM; keep urine drainage bag BELOW BLADDER LEVEL (prevents reflux); empty bag when 2/3 full; assess daily for continued need; REMOVE AS SOON AS POSSIBLE (each additional day increases risk). CAUTI SIGNS: fever without other source, suprapubic tenderness, cloudy or foul-smelling urine (though these alone don't diagnose CAUTI), burning urination when catheter is removed.

CHRONIC PAIN management has evolved significantly with recognition that pain is complex — involving biological, psychological, and social factors (the biopsychosocial model). EVIDENCE-BASED NON-PHARMACOLOGICAL APPROACHES: COGNITIVE-BEHAVIORAL THERAPY (CBT) for pain: most evidence-based psychological approach; addresses catastrophizing, maladaptive thoughts, pain behaviors; improves functioning and quality of life even when pain intensity doesn't fully resolve; MINDFULNESS-BASED STRESS REDUCTION (MBSR): meditation-based approach; reduces pain-related distress; PHYSICAL THERAPY AND EXERCISE: counterintuitive but movement is generally beneficial for most chronic pain (including low back pain); reduces deconditioning and muscle atrophy; HEAT THERAPY: increases blood flow, relaxes muscles; for chronic muscle pain; not for acute inflammation; COLD THERAPY (CRYOTHERAPY): reduces inflammation and acute pain; numbs area; for acute injuries or inflammatory conditions; TENS (Transcutaneous Electrical Nerve Stimulation): low-level electrical current modulates pain signals; evidence moderate; useful adjunct; MASSAGE: reduces muscle tension; improves mood; evidence for some chronic pain types; BIOFEEDBACK: teaches physiological self-regulation; ACUPUNCTURE: evidence for some pain conditions (low back pain, osteoarthritis, headache); DISTRACTION: music therapy, guided imagery, virtual reality (newer, emerging evidence); POSITIONING AND ASSISTIVE DEVICES: proper positioning, orthotic devices for joint pain. MULTIMODAL ANALGESIA: the current standard of care combines multiple approaches (pharmacological and non-pharmacological) at lower doses to achieve pain control while minimizing side effects of any single approach. PN ROLE: teach and implement non-pharmacological measures; assess pain with validated tools (0-10 numeric, FACES, FLACC for children); document pain assessment and response to interventions; advocate for adequate pain management; avoid stigmatizing chronic pain patients.

TOTAL HIP REPLACEMENT (THR) PRECAUTIONS are critical for preventing prosthetic hip dislocation — a serious complication requiring surgical revision. HIP PRECAUTIONS — THE THREE PROHIBITIONS: (1) NO HIP FLEXION GREATER THAN 90 DEGREES: Do not bend the hip past a right angle; no leaning forward in a chair; use a raised toilet seat; no low chairs or couches; (2) NO ADDUCTION (crossing the legs): No crossing legs at knees or ankles; use an abduction pillow between legs when lying in bed; (3) NO INTERNAL ROTATION: No turning toes inward; no lying on the operative side without pillow support; PRACTICAL APPLICATIONS: Dressing: use long-handled adaptive equipment; do not bend to put on socks/shoes; SIT TO STAND: Keep operated leg straight; use chair arm rests to push up; do not lean forward; TOILET: Use elevated toilet seat or bedside commode; SLEEPING: Abduction pillow between legs; avoid lying on operative side initially; DRIVING: No driving until cleared by surgeon (usually 4-8 weeks); these movements require hip flexion beyond 90 degrees; ANTERIOR vs POSTERIOR APPROACH: Hip precautions are traditionally associated with POSTERIOR approach; ANTERIOR approach has fewer or modified precautions — always follow the surgeon's specific orders; PN ROLE: Reinforce precautions with every interaction; set up environment to support compliance; document teaching; report any signs of dislocation (sudden severe pain, leg in shortened and internally rotated position).

NG TUBE PLACEMENT VERIFICATION — CRITICAL SAFETY ISSUE: Feeding through a misplaced NG tube (especially one accidentally in the lung) can cause aspiration pneumonia and death. VERIFICATION METHODS (from most to least reliable): ASPIRATION AND PH TESTING: Aspirate stomach contents; pH of 5.5 or below suggests gastric placement; if pH is above 6, tube may be in small intestine or respiratory tract; X-RAY: Gold standard for confirming initial placement; required for initial placement confirmation before first use in most facilities; MEASUREMENT MARKING: Verify that the external tube marking at the naris matches the documented insertion measurement — migration of the tube is detected this way; VISUAL INSPECTION: Aspirate color (gastric = cloudy/yellow-green; respiratory = clear/white); OUTDATED METHOD: Auscultation ('whoosh' test) — injecting air and listening for sound — is NO LONGER RECOMMENDED as a primary verification method; it has caused deaths when air sound was heard from a tube in the respiratory tract; PN SCOPE: Verify before each feeding or medication; document verification method and results.

HEMIPLEGIA POSITIONING: The AFFECTED SIDE requires special protection because: reduced or absent sensation (cannot feel pain from poor positioning); reduced motor function (cannot shift weight normally); increased muscle tone in abnormal patterns (spasticity); RISKS OF IMPROPER POSITIONING ON AFFECTED SIDE: SHOULDER SUBLUXATION: Shoulder joint may partially dislocate under the weight of the flaccid arm without support; use arm supports in sitting; CONTRACTURES: Without proper positioning and ranging, affected limbs contract in abnormal positions; PRESSURE INJURIES: Bony prominences on the affected side are at highest risk — use pressure-redistributing surfaces; CORRECT POSITIONING: Affected side up: use pillows to support arm in 90-degree shoulder abduction with elbow extended, wrist neutral; Affected side down (possible if turning): brief; requires full padding of shoulder, arm, knee, ankle; GENERAL PRINCIPLES: Neutral joint alignment; no dependent positioning of affected extremities; regular 2-hour repositioning; passive ROM; splints/positioning devices as ordered.

ASPIRATION PRECAUTIONS: POSITIONING: 90° upright (not just slightly elevated) during and 30-45 min after meals — gravity assists swallowing and reduces reflux/aspiration risk; THICKENED LIQUIDS: Thin liquids are the most dangerous for dysphagia — thickening agents (nectar, honey, pudding consistency) as ordered by speech therapy; PACE: Small bites, allow full swallow before next bite, no rushing; SUCTION: Available at bedside in case of aspiration; MONITORING: Watch for coughing, choking, wet/gurgly voice quality after swallowing (sign of aspiration); SPEECH THERAPY: Dysphagia evaluation and specific dietary texture orders should be coordinated with SLP; PN SCOPE: Implement and monitor aspiration precautions; report changes to RN; do not independently modify diet consistency orders.

PRESSURE INJURY STAGING AND DRESSING SELECTION: STAGE 2: Partial thickness skin loss — epidermis and part of dermis; wound appears as shallow open ulcer with red-pink wound bed; MOIST WOUND HEALING: Evidence consistently shows moist wound healing accelerates epithelialisation compared to dry; DRY GAUZE: Creates a dry environment, adheres to wound bed, traumatises healing tissue on removal — NOT appropriate for stage 2; WET-TO-DRY: Appropriate for debridement of necrotic tissue (stage 3-4) — mechanically removes tissue including viable; contraindicated for clean, healing wounds; HYDROCOLLOID: Contains moisture, promotes healing, self-adhesive — appropriate for stage 2 without infection; HYDROFIBER/ALGINATE: For highly exudative wounds; SILVER-CONTAINING: For infected wounds; PN SCOPE: Perform wound assessment, apply ordered dressings, report changes in wound status to RN; do not independently change wound care orders.

CHEST TUBE MANAGEMENT DURING TRANSPORT: DRAINAGE SYSTEM POSITIONING: Must remain upright to maintain the water seal; the water seal prevents air from entering the pleural space; SYSTEM TIPPED: Priority is to return to upright position quickly; if water seal is disrupted (water spilled), notify RN immediately — the seal must be maintained; CLAMPING CONTROVERSY: Chest tubes should NOT be routinely clamped during transport (risk: tension pneumothorax if air is entering and tube is clamped); EXCEPTIONS: Clamp briefly only if the system must be changed, or per specific physician order; DURING TRANSPORT: Keep system below chest level; prevent pulling on the tubing; have clamps available (not applied) in case system disconnects; if tube disconnects, submerge the end in sterile water to restore water seal until replacement system can be set up; PN SCOPE: Monitor the drainage system; report changes; do not independently clamp without RN/provider direction.

TRACHEOSTOMY TUBE SAFETY DURING COUGHING: TUBE DISPLACEMENT RISK: Coughing generates significant intrathoracic pressure — a tracheostomy tube, especially one within the first 7-10 days of placement (before the stoma tract is established), can be expelled from the stoma; if this happens, the airway may close rapidly; NURSING ACTION: Pause the procedure; SECURE the tube — place a hand on the tube or hold the flanges to prevent accidental decannulation; allow the cough to complete naturally; suction if secretions are in the airway after coughing; DECANNULATION EMERGENCY SUPPLIES: An extra tracheostomy tube of the same size and one size smaller should be at the bedside at all times; tracheal dilators should be available; AFTER COUGHING: Assess breath sounds; assess tube placement (air movement through the tube); assess skin colour and SpO2; resume procedure only when stable; PN SCOPE: Perform routine tracheostomy care per protocol; report any concerns about tube placement or client distress to RN immediately.

ORAL CARE FOR UNCONSCIOUS CLIENTS: ASPIRATION RISK: Unconscious clients have no protective gag reflex — fluid, secretions, or debris can enter the airway; POSITIONING: Side-lying is ideal — gravity drains secretions away from the airway; if patient cannot be turned, turn the head to the side; TECHNIQUE: Use minimal fluid (moistened swabs rather than rinse); suction available and ready to use; small, controlled applications; avoid over-suctioning (mucosal trauma); FREQUENCY: Every 2-4 hours in mechanically ventilated patients (oral care reduces VAP — ventilator-associated pneumonia); SUPPLIES: Oral swabs, dilute chlorhexidine rinse (ICU/ventilated patients per evidence), lip moisturiser, suction; EVIDENCE-BASED: Regular oral care in ICU patients reduces VAP incidence by approximately 40%; PN SCOPE: Perform routine oral care; assess oral mucosa; report signs of infection or breakdown; ensure suction equipment is functioning before providing care to unconscious patients.

DYSPHAGIA ASPIRATION PREVENTION: POSITIONING: High Fowler's (90 degrees upright) during meals; CHIN TUCK: Slightly tucking the chin toward the chest narrows the airway entrance and directs food toward the esophagus — reduces aspiration; REMAIN UPRIGHT: 30-60 minutes after eating prevents reflux and aspiration; ADDITIONAL MEASURES: Thickened liquids (per speech therapy/swallow evaluation — thin liquids are most easily aspirated); small bites; alternate solids and liquids; have suction available; feed slowly; assess for pocketing food in cheeks; ASPIRATION SIGNS: Coughing during/after eating, wet/gurgly voice, throat clearing, watery eyes; ASPIRATION PNEUMONIA RISK: Aspiration of food/fluid into lungs causes pneumonia — a leading cause of post-stroke death; SPEECH THERAPY: Conducts formal swallow evaluation and determines diet texture; LPN follows the established swallowing precautions.

COLOSTOMY CARE TEACHING: CORRECT statements (no further teaching needed): Empty pouch at 1/3 to 1/2 full (prevents weight pulling appliance off and leakage); Stoma should be PINK/RED and MOIST (healthy perfusion — report pale, dusky, purple, or black stoma immediately = ischemia); Odor management with diet awareness (eggs, fish, garlic, onions increase odor); INCORRECT statement (needs teaching): Applying barrier to moist/weepy skin — the skin MUST be clean and completely DRY for the skin barrier (wafer) to adhere; moisture prevents adhesion and causes leakage and skin breakdown; STOMA ASSESSMENT: Healthy = pink/red, moist, slightly raised; CONCERNING = pale (anemia/poor perfusion), dark/dusky/purple/black (ischemia/necrosis - EMERGENCY); PERISTOMAL SKIN: Should be intact; protect from effluent with proper barrier fit; report excoriation; LPN role: reinforce ostomy teaching, assess stoma, support client adjustment.

PRESSURE INJURY PREVENTION — REPOSITIONING: Reposition bedbound clients at least every 2 hours (chair-bound: every 1 hour or teach weight shifts every 15 minutes); WHY: Pressure over bony prominences (sacrum, heels, hips, elbows, occiput) compresses capillaries, causing tissue ischemia; unrelieved pressure for as little as 2 hours can begin tissue damage; PREVENTION BUNDLE: Repositioning schedule; pressure-redistributing surfaces (specialty mattress); keep skin clean and dry; manage moisture (incontinence); adequate nutrition and hydration (protein for tissue integrity); float heels off the bed; avoid friction and shear (lift, don't drag); use the Braden Scale to assess risk; PRESSURE INJURY STAGES: Stage 1 (non-blanchable erythema, intact skin) through Stage 4 (full thickness with exposed bone/muscle), plus unstageable and deep tissue injury; LPN role: reposition per schedule, assess skin every shift, document, report any skin changes (early Stage 1 is reversible with intervention).

FLUID RESTRICTION MANAGEMENT: Distribute the daily allotment to match the client's activity and needs — more during waking/meal hours, less at night. TYPICAL DISTRIBUTION (1,500 mL example): Day (7a-3p): ~800 mL (breakfast, lunch, morning/noon meds, most active); Evening (3p-11p): ~500 mL (dinner, evening meds); Night (11p-7a): ~200 mL (minimal, just for night meds if needed); RATIONALE: Accommodates meals and medications; respects the client's normal drinking patterns; prevents the client from using the entire allotment early and being thirsty all evening/night; PRACTICAL MEASURES: Use smaller cups (perception of more fluid); ice chips (count as 1/2 their volume); frequent oral care for thirst; sugar-free hard candy or gum to stimulate saliva; involve the client in planning; track ALL intake (IV, meds, foods that are liquid at room temp like gelatin and ice cream); CONDITIONS requiring fluid restriction: heart failure, SIADH, renal failure, hyponatremia; LPN role: distribute and track fluids, educate the client, manage thirst.