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.
General CNA Practice CNA Practice Documentation and Reporting 2
What does the term 'subjective data' mean in nursing documentation?