General CNA Practice CNA Practice Documentation and Reporting 1

Question 1

When should a CNA document care provided to a resident?

Accepted Answer

After completing the care

Answer

Before starting the care

Answer

At the end of the shift only

Answer

When the supervisor requests it

Question 2

Which abbreviation is commonly used in medical records to mean 'as needed'?

Accepted Answer

PRN

Answer

QID

Answer

STAT

Answer

NPO

Question 3

What is the FIRST action a CNA should take when noticing a change in a resident's condition?

Accepted Answer

Report the change to the nurse immediately

Answer

Document the change in the medical record

Answer

Call the resident's family

Answer

Wait to see if the condition improves on its own

Question 4

Which of the following is the correct way to correct a documentation error in a paper medical record?

Accepted Answer

Draw a single line through the error, write 'error,' initial, and date it

Answer

Use correction fluid (white-out) to cover the mistake

Answer

Erase the error completely so it cannot be read

Answer

Tear out the page and rewrite the entry

Question 5

What is the primary purpose of an incident report?

Accepted Answer

To document unexpected events in order to improve safety and prevent recurrence

Answer

To assign blame and punish the staff member responsible

Answer

To notify the resident's family about all problems

Answer

To cancel the resident's existing care plan

Question 6

Which of the following is an example of objective data when documenting a resident's condition?

Accepted Answer

Temperature reading of 101.2°F

Answer

Resident appears to be in pain

Answer

Resident seems anxious today

Answer

Resident looks pale to staff

Question 7

A resident refuses to have their blood pressure taken. How should the CNA document this?

Accepted Answer

Record that the resident refused the procedure and the time it occurred

Answer

Skip documentation since the procedure was not completed

Answer

Write 'unable to perform' without any further explanation

Answer

Document an estimated reading based on prior values