HCA - Health Care Assistant Documentation and Legal Ethics Questions and Answers

Question 1

While documenting in a resident's paper chart, a Health Care Assistant realizes they wrote down the wrong time for when a task was completed. What is the correct procedure for fixing this error?

Accepted Answer

Draw a single line through the incorrect time, write "error" or "mistaken entry" above it with their initials, and then record the correct time.

Answer

Use correction fluid to completely cover the incorrect time and write the correct time over it.

Answer

Tear out the page and start a new one to ensure the chart is neat and legible.

Answer

Leave the incorrect entry as is and make a note about the correct time later in the day.

Question 2

Which of the following is the best example of objective information a Health Care Assistant should document?

Accepted Answer

A red, raised rash is observed on the client's left arm.

Answer

The client's wife says he "didn't sleep well last night."

Answer

The client states, "I feel very nauseous."

Answer

The client seems more confused than usual today.

Question 3

A Health Care Assistant notices several unexplained bruises on a resident who is unable to communicate verbally. The resident flinches when the HCA gently touches their arm. What is the HCA's primary legal and ethical responsibility?

Accepted Answer

Immediately report their objective observations to their supervising nurse according to facility policy.

Answer

Ask the resident's family members if they know the cause of the bruises.

Answer

Document the findings and monitor the resident for any new injuries.

Answer

Wait until the end of the shift to discuss the findings with other HCAs.

Question 4

A client's care plan includes a valid Do Not Resuscitate (DNR) order. This legal document specifically instructs the healthcare team to do which of the following?

Accepted Answer

Not perform cardiopulmonary resuscitation (CPR) if the client stops breathing or their heart stops.

Answer

Withhold all forms of medical treatment, including pain medication.

Answer

Consult with the family before providing any comfort care measures.

Answer

Provide a lower standard of daily care than what is given to other clients.

Question 5

Which of the following tasks falls outside the typical scope of practice for a Health Care Assistant?

Accepted Answer

Documenting observations about a client's appetite and fluid intake.

Answer

Assisting a resident with their personal hygiene and grooming.

Answer

Measuring and recording a client's height and weight.

Answer

Independently adjusting the dosage of a client's insulin based on a blood sugar reading.

Question 6

A resident expresses that they are feeling lonely and sad. Which action by the Health Care Assistant best demonstrates the ethical principle of beneficence?

Accepted Answer

Offering to sit and talk with the resident for a few minutes or suggesting a quiet activity they enjoy.

Answer

Telling the resident that they need to be more positive.

Answer

Leaving the resident alone to respect their privacy.

Answer

Informing the resident that everyone feels sad sometimes.

While documenting in a resident's paper chart, a Health Care Assistant realizes they wrote down the wrong time for when a task was completed.What is the correct procedure for fixing this error?

While documenting in a resident's paper chart, a Health Care Assistant realizes they wrote down the wrong time for when a task was completed.
What is the correct procedure for fixing this error?