General CNA Practice CNA Practice Documentation and Reporting 2

Question 1

What does the term 'subjective data' mean in nursing documentation?

Accepted Answer

Information reported by the resident about how they feel

Answer

Measurements taken with medical equipment

Answer

Observations made directly by the CNA

Answer

Lab test results ordered by the physician

Question 2

What does 'NPO' mean in medical documentation?

Accepted Answer

Nothing by mouth

Answer

No procedures ordered

Answer

Not physically oriented

Answer

Normal pulse observed

Question 3

A resident's skin shows new redness over their coccyx. What should the CNA do FIRST?

Accepted Answer

Report the finding to the nurse immediately

Answer

Apply lotion to the area without reporting

Answer

Document it and wait until the next shift to report

Answer

Turn the resident and reassess in one hour

Question 4

Which of the following is true about confidentiality in documentation?

Accepted Answer

Medical records should only be shared with those directly involved in the resident's care

Answer

Any staff member can access any resident's chart at any time

Answer

Family members always have unrestricted access to all medical records

Answer

Documentation can be discussed openly at the nurses' station

Question 5

What is a care plan in the nursing home setting?

Accepted Answer

A written document outlining individualized goals and interventions for a specific resident

Answer

A schedule of when all medications are administered

Answer

A master list of all residents' diagnoses in the facility

Answer

A daily meal plan created by the dietitian for the resident

Question 6

During a shift change report, what is the most important information to communicate to the incoming staff?

Accepted Answer

Any changes in the resident's condition that occurred during the shift

Answer

The CNA's personal opinions and feelings about each resident

Answer

Complaints about coworkers from during the shift

Answer

Which residents were the most difficult to work with

Question 7

When must vital signs be documented after they are obtained?

Accepted Answer

Immediately after they are taken

Answer

At the end of the shift in a batch

Answer

Before reporting them to the nurse

Answer

Only when abnormal values are found