CNA Vital Signs and Measurements 4

Question 1

A CNA is measuring a patient's blood pressure and obtains a reading of 118/76 mmHg on the right arm. When the same patient's BP is measured on the left arm immediately after, the reading is 132/78 mmHg. What is the most appropriate next action?

Accepted Answer

Report the discrepancy to the nurse, as a difference greater than 10 mmHg between arms may indicate a vascular abnormality

Answer

A systolic blood pressure difference of more than 10 mmHg between arms is clinically significant and may indicate conditions such as peripheral artery disease, aortic dissection, or subclavian artery stenosis. The CNA must report this finding to the nurse for further evaluation rather than averaging, ignoring, or simply repeating the measurement.

Question 2

While counting a patient's respirations, the CNA notices that the breathing pattern consists of progressively deeper breaths followed by progressively shallower breaths, with brief periods of apnea in between. Which term correctly describes this pattern, and what condition is it most commonly associated with?

Accepted Answer

Cheyne-Stokes respirations; heart failure or neurological impairment

Answer

Cheyne-Stokes respirations are characterized by a cyclical pattern of gradually increasing then decreasing depth, followed by a period of apnea. This pattern is classically associated with heart failure, stroke, brain injury, and end-of-life states. Kussmaul is deep and rapid (DKA), Biot's is irregular without a crescendo-decrescendo pattern, and apneustic involves prolonged inspiratory pauses.

Question 3

A CNA is assigned to measure the rectal temperature of an adult patient. After inserting the lubricated thermometer approximately 1 inch into the rectum, the patient begins to bear down and the thermometer is pushed outward. What should the CNA do?

Accepted Answer

Reinsert the thermometer and hold it firmly in place throughout the entire measurement period

Answer

The CNA should never leave a rectal thermometer unattended, and holding the thermometer securely in place throughout measurement is standard protocol to prevent accidental expulsion, breakage, or rectal injury. Switching methods mid-measurement is not clinically equivalent, adding 1°F is not a validated substitute for rectal measurement, and increasing insertion depth beyond 1 inch in adults risks injury.

Question 4

A patient who is receiving supplemental oxygen at 4 L/min via nasal cannula has a pulse oximetry reading of 97%. The nurse asks the CNA to document the SpO₂ along with the relevant context. Which documentation entry is most complete and clinically accurate?

Accepted Answer

SpO₂ 97% on 4 L/min O₂ via nasal cannula, patient at rest

Answer

Accurate SpO₂ documentation must always include the oxygen delivery method, flow rate, and patient's activity level or position, because an SpO₂ of 97% on supplemental oxygen conveys very different clinical information than 97% on room air. Omitting the oxygen details (as in answer B) is a critical documentation error. Vague entries like 'amount unknown' are unacceptable in clinical records.

Question 5

When palpating a patient's radial pulse, the CNA notices that the strength of the pulse varies noticeably — some beats feel strong and others feel weak — even though the rhythm appears regular. This finding is best described as:

Accepted Answer

Pulsus alternans

Answer

Pulsus alternans is a pattern of alternating strong and weak pulse beats occurring at a regular rate, most commonly associated with left ventricular dysfunction or heart failure. A pulse deficit refers to a difference between apical and radial rates. A thready pulse is consistently weak throughout. Bradycardia with skipped beats would present as an irregular rhythm, not a regular rhythm with alternating amplitudes.

CNA Practice Test

CNA Practice Test

CNA Vital Signs and Measurements 4