CNA Documentation and Reporting 2 — Questions and Answers
Question 1: A resident suddenly becomes confused and disoriented. What is the CNA's priority action?
- Document the change in the medical record
- Report the change immediately to the charge nurse (Correct answer)
- Ask a family member what to do
- Wait to see if the confusion resolves on its own
Correct answer: Report the change immediately to the charge nurse
Sudden changes in mental status must be reported to the charge nurse immediately as they can signal a serious medical condition.
Question 2: Which communication tool uses the format Situation, Background, Assessment, Recommendation when reporting to a nurse?
- SOAP
- SBAR (Correct answer)
- DAR
- PIE
Correct answer: SBAR
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used in healthcare to relay important patient information.
Question 3: Which observation requires the MOST immediate report to the charge nurse?
- A resident's skin appears dry
- A resident requests an extra blanket
- A resident's lips are turning blue (Correct answer)
- A resident ate only half of their lunch
Correct answer: A resident's lips are turning blue
Cyanosis (blue-colored lips) indicates possible oxygen deprivation and is an emergency requiring immediate reporting.
Question 4: A resident tells the CNA they are experiencing chest pain. What should the CNA do FIRST?
- Help the resident to bed and give them water
- Document the complaint and finish the current task
- Notify the charge nurse immediately and stay with the resident (Correct answer)
- Ask the resident to describe the pain in detail before reporting
Correct answer: Notify the charge nurse immediately and stay with the resident
Chest pain is a potential cardiac emergency; the CNA must notify the nurse immediately and remain with the resident.
Question 5: Which of the following is an example of OBJECTIVE data a CNA should document?
- The resident seems depressed today
- The resident appeared uncomfortable during care
- The resident's oral temperature was 101.2°F (Correct answer)
- The resident looked like they were in pain
Correct answer: The resident's oral temperature was 101.2°F
Objective data is measurable and observable; a numeric temperature reading is objective, while words like 'seemed' or 'appeared' are subjective interpretations.
Question 6: A family member asks to read their adult parent's medical chart. The CNA should:
- Hand them the chart since they are family
- Tell them to speak with the charge nurse (Correct answer)
- Decline and explain no one can see the chart
- Allow access only if the resident is asleep
Correct answer: Tell them to speak with the charge nurse
Medical record access decisions are made by licensed staff and administration in accordance with HIPAA; the CNA should redirect the family to the charge nurse.
Question 7: When is the BEST time for a CNA to document care that was provided?
- At the end of the shift all at once
- Before providing the care
- As soon as possible after providing the care (Correct answer)
- Only when the charge nurse requests it
Correct answer: As soon as possible after providing the care
Documentation should occur as soon as possible after care is given to ensure accuracy and completeness of the medical record.
CNA Documentation and Reporting 2
A resident suddenly becomes confused and disoriented.
What is the CNA's priority action?