Documentation and Reporting Flashcards
7 cards from real CNA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Reporting flashcards as text
When documenting intake and output (I&O), which of the following counts as OUTPUT?
Answer: Urine, vomitus, and wound drainage
Output includes all fluids leaving the body: urine, emesis (vomit), wound drainage, and diarrhea; inputs are all fluids entering the body.
A resident's blood pressure reads 180/110 mmHg. This reading is best described as:
Answer: Hypertensive and must be reported immediately
A blood pressure of 180/110 mmHg is severely elevated (hypertensive) and must be reported to the charge nurse immediately due to risk of stroke or cardiac event.
Which vital sign value should a CNA report to the charge nurse IMMEDIATELY?
Answer: Oxygen saturation of 88%
An oxygen saturation of 88% is critically low (normal is 95-100%); it indicates inadequate oxygenation and requires immediate nursing assessment.
What does the medical abbreviation 'PRN' mean?
Answer: As needed
PRN stands for 'pro re nata,' a Latin phrase meaning 'as needed,' used to indicate care or medication given only when a specific condition arises.
When completing a flow sheet, the CNA should:
Answer: Record each task immediately after it is performed
Flow sheets should be completed in real time as each task is performed to maintain accuracy and reduce the risk of errors or omissions.
An incident report is completed when a resident's fall injures a staff member. Who should fill out the incident report?
Answer: Both the injured staff member and the CNA who witnessed the event may need separate reports
Incident reports are completed by those directly involved or who witnessed the event; multiple reports may be required if more than one person is affected.
A resident's appetite has significantly decreased for three consecutive days. Where should a CNA document this observation?
Answer: In the resident's medical record and in a verbal report to the charge nurse
Significant changes like decreased appetite must be recorded in the official medical record and reported verbally to the charge nurse to ensure proper follow-up.