General CNA Practice CNA Practice Documentation and Reporting 2 — Questions and Answers
Question 1: What does the term 'subjective data' mean in nursing documentation?
- Information reported by the resident about how they feel (Correct answer)
- Measurements taken with medical equipment
- Observations made directly by the CNA
- Lab test results ordered by the physician
Correct answer: Information reported by the resident about how they feel
Subjective data is what the resident tells you about their own experience, such as reporting pain, nausea, or dizziness.
Question 2: What does 'NPO' mean in medical documentation?
- Nothing by mouth (Correct answer)
- No procedures ordered
- Not physically oriented
- Normal pulse observed
Correct answer: Nothing by mouth
NPO (from Latin 'nil per os') means nothing by mouth, indicating the resident must not eat or drink anything.
Question 3: A resident's skin shows new redness over their coccyx. What should the CNA do FIRST?
- Report the finding to the nurse immediately (Correct answer)
- Apply lotion to the area without reporting
- Document it and wait until the next shift to report
- Turn the resident and reassess in one hour
Correct answer: Report the finding to the nurse immediately
New skin changes should be reported to the nurse immediately so assessment and interventions can begin before the condition worsens.
Question 4: Which of the following is true about confidentiality in documentation?
- Medical records should only be shared with those directly involved in the resident's care (Correct answer)
- Any staff member can access any resident's chart at any time
- Family members always have unrestricted access to all medical records
- Documentation can be discussed openly at the nurses' station
Correct answer: Medical records should only be shared with those directly involved in the resident's care
HIPAA requires that medical information be shared only with those who have a legitimate need to know for care purposes.
Question 5: What is a care plan in the nursing home setting?
- A written document outlining individualized goals and interventions for a specific resident (Correct answer)
- A schedule of when all medications are administered
- A master list of all residents' diagnoses in the facility
- A daily meal plan created by the dietitian for the resident
Correct answer: A written document outlining individualized goals and interventions for a specific resident
A care plan is an individualized document that outlines specific goals, identified needs, and planned interventions tailored to each resident.
Question 6: During a shift change report, what is the most important information to communicate to the incoming staff?
- Any changes in the resident's condition that occurred during the shift (Correct answer)
- The CNA's personal opinions and feelings about each resident
- Complaints about coworkers from during the shift
- Which residents were the most difficult to work with
Correct answer: Any changes in the resident's condition that occurred during the shift
Changes in condition are critical to communicate during handoff so incoming staff can prioritize monitoring and care accordingly.
Question 7: When must vital signs be documented after they are obtained?
- Immediately after they are taken (Correct answer)
- At the end of the shift in a batch
- Before reporting them to the nurse
- Only when abnormal values are found
Correct answer: Immediately after they are taken
Vital signs should be documented immediately after measurement to ensure accuracy and timely availability of the information to the care team.
