- NNAAP — what is it?
- The National Nurse Aide Assessment Program — the exam most states use to certify CNAs.
- NNAAP — two parts
- A written (or oral) knowledge test AND a hands-on skills evaluation; you must pass both.
- Who administers the NNAAP?
- Credentia (it took over from Pearson VUE around 2018-2019).
- Written test — # of questions
- 70 multiple-choice (60 scored + 10 unscored pretest).
- Written test — scored vs pretest
- 60 scored questions count; 10 pretest questions don't — answer all 70 as if they count.
- Written test — time limit
- 2 hours (120 minutes).
- Skills evaluation — # of skills
- 5 skills, and you must pass all 5 of 5.
- Skills evaluation — time limit
- About 30 minutes for all five skills.
- Which skill is ALWAYS first?
- Hand hygiene (handwashing) — it's Skill 1 every time.
- Skills evaluation — composition
- 1 hand hygiene + 1 measurement skill + 3 randomly selected skills.
- What is a measurement skill?
- A skill that produces a recorded value: BP, pulse, respirations, weight, or output. One is always tested.
- Critical Element Step
- A make-or-break step on a skill checklist; missing one is an automatic fail of that whole skill.
- Indirect care
- Communication, privacy, dignity & safety steps scored INSIDE every skill, not tested separately.
- Can you verbalize skill steps?
- Only later handwashing may be verbalized; every other step of every skill is physically performed.
- Incomplete skill at time-up?
- Scored as a fail — pace yourself ~5-6 minutes per skill and keep moving.
- Oral exam option
- 60 multiple-choice read aloud + 10 reading-comprehension, for those who read English with difficulty.
- Passing standard — written
- A scaled cut score (not a fixed %); commonly reported around 70-80% correct.
- Do you pass parts together?
- No — each part is scored independently; you retake only the part you failed.
- Eligibility — federal minimum
- Complete a state-approved training program: 75+ hours including 16+ clinical (OBRA '87).
- NATCEP
- Nurse Aide Training and Competency Evaluation Program — the state-approved course you must finish to test.
- Which states use the NNAAP?
- Most U.S. states; a number use Prometric and some use a state-specific vendor.
- Example NNAAP fees
- Roughly $45 written + $95 skills, about $140 combined; varies by state, non-refundable.
- NNAAP retake policy
- A new fee for each part retaken; many states allow ~3 attempts before requiring retraining.
- After passing both parts
- You're listed on your State Nurse Aide Registry and can work as a CNA.
- OBRA 24-month rule
- No paid nursing duties for 24 straight months = you must re-test to stay on the registry.
- Test-day ID
- A valid, unexpired government photo ID whose name matches your registration exactly.
- The 'client' in the skills test
- A live volunteer who plays the resident while you perform the five skills.
- Universal skill frame
- Introduce + name client → explain → privacy → perform → call light in reach + bed low.
- Why candidates fail the skills test
- Usually the rules (verbalizing, time, missing indirect care), not the nursing technique.
- This guide vs the CNA guide
- This = how the exam works; the CNA study guide = the deep clinical content it tests.
- Standard Precautions
- Treat ALL blood and body fluids of EVERY resident as potentially infectious, every time.
- #1 way to prevent infection
- Hand hygiene (handwashing).
- How long to lather hands
- At least 20 seconds with friction, fingertips down, hands below the elbows.
- Why fingertips point down
- So dirty water runs off the fingertips, not back up the clean arms.
- Never touch during handwashing
- The inside of the sink — it's a Critical Element Step.
- Turn off faucet with...
- A clean, dry paper towel (not your bare clean hand).
- PPE — donning (putting on) order
- Gown → mask → goggles → gloves.
- PPE — doffing (taking off) order
- Gloves → goggles → gown → mask.
- Why gloves come off first
- They are the most contaminated item — remove them before they touch clean skin.
- After removing all PPE
- Wash your hands.
- Contact Precautions
- Gown + gloves for organisms spread by touch (MRSA, C. diff, scabies).
- Droplet Precautions
- A surgical mask for influenza, pertussis, mumps.
- Airborne Precautions
- An N95 respirator + negative-pressure room for TB, measles, chickenpox.
- C. diff hand hygiene
- Soap and water, NOT alcohol gel — gel doesn't kill the spores.
- Normal adult pulse
- 60-100 beats per minute.
- Report a pulse if...
- Under 60 or over 100 bpm.
- Normal adult respirations
- 10-20 breaths per minute.
- Report respirations if...
- Under 10 or over 20 per minute.
- Normal adult blood pressure
- About 91-129 / 61-89 mmHg.
- Report a BP if...
- At or above 130/90 mmHg (hypertension).
- Normal oral temperature
- About 96-99°F (35.8-37.3°C).
- Report a temperature over...
- 100.4°F (38°C).
- Normal oxygen saturation
- 95-100%; report under 90%.
- Systolic vs diastolic
- Systolic = top number (heart contracts); diastolic = bottom (heart rests).
- How long to count a pulse
- A full 60 seconds (apical or radial).
- How to count respirations
- Without telling the resident, so they breathe naturally; one rise + fall = one breath.
- Which temperature reads highest?
- Rectal reads highest; axillary (armpit) reads lowest.
- Body mechanics rule
- Bend the knees and hips, wide base, lift with the legs, hold loads close — never twist.
- Lifting a heavy resident
- Get help or use a mechanical lift; never lift alone.
- Leaving a resident's room
- Call light in reach, bed in its lowest position, wheels locked.
- RACE (fire)
- Rescue, Alarm, Confine, Extinguish (or Evacuate).
- PASS (fire extinguisher)
- Pull the pin, Aim at the base, Squeeze the handle, Sweep side to side.
- Aim a fire extinguisher at...
- The base of the flames, not the top.
- Restraints require...
- A physician's order; a last resort, never for staff convenience or punishment.
- Reposition an immobile resident
- At least every 2 hours to prevent pressure injuries.
- Pressure injury (bedsore)
- Skin/tissue damage from constant pressure over a bony area.
- Where pressure injuries form
- Over bony areas: sacrum, hips, heels, elbows.
- Objective vs subjective data
- Objective = measured/observed; subjective = what the resident reports.
- The CNA's documentation rule
- Chart factually, after care is given — never chart care you didn't perform.
- Observe, record, report
- The CNA's core duty — report any abnormal value or change to the nurse immediately.
- Choking — conscious adult
- Abdominal thrusts (Heimlich maneuver).
- Aspiration
- Inhaling food/fluid into the lungs — prevent it with upright positioning during feeding.
- First action for any abnormal vital
- Report it to the nurse — never diagnose, medicate, or wait.
- Gloves are worn when...
- There is contact with blood, body fluids, broken skin, or mucous membranes.
- ADLs
- Activities of Daily Living: bathing, dressing, grooming, toileting, eating, mobility.
- Golden ADL principle
- Do only what the resident cannot — encourage them to do as much as they safely can.
- Dressing a weak (affected) arm
- Weak side goes IN first; strong side comes OUT first.
- Memory rule for dressing
- Weak goes in first, strong comes out first.
- Safe bath-water temperature
- About 105°F (40.5°C) — test it before bathing.
- Washing the eyes
- Inner corner to outer corner, clean part of the cloth for each eye.
- Bathing — direction
- Wash from clean to dirty.
- Perineal care for a female
- Always wipe front to back, clean cloth area for each stroke.
- Why wipe front to back
- To prevent spreading bacteria from the anus to the urethra (UTI prevention).
- Position for feeding
- Upright at 90° (high Fowler's); stay upright 30-60 min after.
- Feeding technique
- Small bites, slowly, alternate food and fluids, allow time to chew and swallow.
- Dysphagia
- Difficulty swallowing; follow the care plan for thickened liquids.
- Catheter drainage bag position
- Below the level of the bladder, off the floor.
- Recording fluids
- Intake and Output (I&O), measured in mL/cc.
- NPO
- Nothing by mouth — the resident may not eat or drink.
- Denture care
- Line/pad the sink so they don't break; use cool/tepid water, not hot.
- Mouth care — unconscious resident
- Turn the head to the side to prevent aspiration; wear gloves.
- Foot care
- Dry between the toes; lotion everywhere EXCEPT between the toes; don't cut nails.
- Brushing/combing hair
- Per the resident's preference; never cut hair.
- Shaving with a safety razor
- Wear gloves; shave in the direction of hair growth.
- Fowler's position
- Semi-sitting, head of bed raised 45-60°; used for eating and breathing.
- Supine position
- Lying flat on the back.
- Prone position
- Lying on the abdomen, face down.
- Lateral position
- Lying on the side; relieves pressure on the back.
- Sims' position
- Left side-lying, partly prone, upper knee flexed; for enemas.
- Oral care frequency
- At least twice a day and as needed; provides comfort and prevents infection.
- Signs to report at bath time
- Reddened skin, rashes, broken skin, bruises, swelling — observe and report.
- Promoting independence in ADLs
- Offer adaptive devices and let the resident do the task, even if slower.
- Restorative care
- Care that helps a resident regain/keep the highest possible function and prevents decline.
- Range of motion (ROM)
- Moving a joint through its normal movements to keep flexibility and prevent contractures.
- Active vs passive ROM
- Active = resident moves; passive = the aide moves the joint. Active is preferred.
- ROM safety rule
- Support the joint above and below; move to resistance, NOT pain; never force.
- Contracture
- Permanent tightening/shortening of a muscle or joint from disuse — prevent with ROM.
- Atrophy
- Muscle wasting from disuse.
- Which side holds a cane?
- The STRONG (unaffected) side.
- Up with the good, down with the bad
- Lead with the strong leg going up stairs, the weak leg going down.
- Gait belt (transfer belt)
- Worn snug around the waist over clothing to assist transfers and walking.
- Walking with a resident
- Walk slightly behind and to the weaker side; use non-skid footwear.
- If a resident starts to fall
- Ease them to the floor, protect the head — don't try to hold them up.
- Goal of restorative care
- Maximum independence and prevention of complications of immobility.
- Preventing pressure injuries
- Reposition every 2 hours; keep skin clean and dry.
- Restoring continence
- Scheduled toileting plus adequate fluids and fiber per the care plan.
- Adaptive devices
- Tools (built-up utensils, plate guards, sock aids) that help a resident self-care.
- Transfer rule — wheelchair
- Lock the wheels and raise the footrests before transferring.
- Lock before transfer
- Lock the bed and wheelchair wheels every time.
- Non-skid footwear
- Required before standing or walking a resident, to prevent falls.
- Repeat each ROM movement
- The number of times in the care plan (commonly about 3-5).
- Restorative philosophy
- Promote independence — let residents do what they can, praise the effort.
- Maslow's hierarchy — first need
- Physiological needs (food, water, oxygen) come first, then safety.
- Defense mechanism
- An unconscious way of coping with stress or anxiety.
- Denial
- Refusing to accept a painful reality.
- Projection
- Attributing one's own feelings to someone else.
- Regression
- Returning to earlier, childlike behavior.
- Rationalization
- Making excuses to justify behavior.
- Displacement
- Redirecting emotion onto a safer target.
- Dementia
- Progressive, irreversible loss of memory, judgment, and reasoning.
- Most common type of dementia
- Alzheimer's disease.
- Communicating with dementia
- Approach from the front, simple one-step instructions, calm voice, redirect & validate.
- Sundowning
- Increased confusion/agitation in the late afternoon or evening.
- Managing sundowning
- More evening light, less noise, a calm, consistent routine.
- Reality orientation vs validation
- Don't argue with a firmly confused resident — redirect or validate instead.
- Wandering — wrong response
- Never restrain a resident just to stop wandering; make the area safe and supervise.
- Depression in older adults
- NOT a normal part of aging — report withdrawal, appetite/sleep changes.
- Statement of self-harm
- Report to the nurse immediately — never keep it confidential.
- Five stages of grief
- Denial, anger, bargaining, depression, acceptance — no fixed order.
- Aide's role in grief
- Listen and support; never push a resident toward acceptance.
- Hospice care
- Comfort care for someone expected to live about 6 months or less.
- Palliative care
- Comfort and symptom relief, which can be given alongside treatment at any stage.
- Last sense lost when dying
- Hearing — keep speaking gently to a dying resident.
- Postmortem care
- Care of the body after death, done with dignity and per policy/family wishes.
- Aide's role with beliefs
- Respect and support the resident's beliefs — never judge, change, or impose your own.
- Religious items
- Handle with care; provide privacy for prayer or clergy visits.
- Religious/cultural diets
- Honor kosher, halal, vegetarian per the care plan; never serve a forbidden food.
- Resident with no religion
- Respect them equally — never preach or push beliefs.
- Culture affects...
- Communication, personal space, eye contact, modesty, family roles, and diet.
- When a custom differs from yours
- Respect and accommodate it; tell the nurse if you can't.
- Modesty in care
- Provide draping and honor requests for same-gender care.
- Death & dying customs
- Follow the resident's and family's wishes for the body; report to the nurse.
- Verbal vs nonverbal communication
- Verbal = spoken/written words; nonverbal = body language, tone, eye contact, touch.
- Therapeutic communication
- Face the resident, sit at eye level, allow silence, use open-ended questions.
- Avoid false reassurance
- Don't say 'you'll be fine' — it shuts down real concerns.
- Elderspeak
- Talking down/baby-talk to an older adult — avoid it; it's disrespectful.
- Hearing-impaired resident
- Face them, LOWER your pitch (don't shout), reduce background noise, check hearing aids.
- Why not shout at hearing loss
- Shouting raises pitch and distorts sound — lower your pitch instead.
- Vision-impaired resident
- Announce yourself before touching; describe the surroundings; use the clock method for food.
- Aphasia / speech-impaired
- Allow time, don't finish sentences, ask yes/no questions, use communication boards.
- Reporting vs recording
- Reporting = telling the nurse verbally; recording = writing it in the chart.
- Open-ended question
- A question that encourages the resident to talk, not just say yes or no.
- Active listening
- Give full attention, make eye contact, and show you understand.
- Clock method
- Describing food location on a plate by clock position for a vision-impaired resident.
- Confidential conversations
- Never discuss a resident in public areas or on social media (HIPAA).
- Residents' rights source
- The Federal Nursing Home Reform Act (OBRA '87), 42 CFR 483.10.
- Key residents' rights
- Privacy, choice, dignity, voice grievances, refuse care, freedom from abuse/restraints.
- Right to refuse care
- A competent resident may refuse any care or treatment — honor it and report it.
- Mandated reporter
- A CNA must report suspected abuse or neglect immediately — to the nurse.
- Reporting abuse
- Report a suspicion; you don't need proof and don't confront the abuser yourself.
- Abuse
- Intentional harm: physical, verbal/psychological, sexual, or financial.
- Neglect
- Failure to provide the goods or services a resident needs to avoid harm.
- Involuntary seclusion
- Confining a resident against their will — a form of abuse.
- HIPAA
- Protects Protected Health Information (PHI) — share only on a need-to-know basis.
- Privacy during care
- Close the door/curtain, drape the resident, knock before entering.
- Addressing a resident
- By their preferred name — never 'honey,' 'sweetie,' or a room number.
- Ombudsman
- An advocate who investigates and resolves residents' complaints.
- Right to personal possessions
- Residents may keep and use personal belongings.
- Grievances
- Residents may voice complaints without fear of retaliation.
- Financial exploitation
- Misusing a resident's money or property — a form of abuse, report it.
- Quality of life
- Residents have the right to dignity, respect, and to make their own choices.
- Restraint as a right violation
- Improper restraint can be abuse and false imprisonment.
- Negligence
- Failing to give the care a reasonable aide would, resulting in harm.
- Assault
- A threat that makes someone fear harm — no contact needed.
- Battery
- Touching a person without consent (e.g., forcing care on someone who refused).
- Assault vs battery
- Assault is the threat; battery is the unwanted touch.
- False imprisonment
- Unlawfully restricting freedom of movement (e.g., restraining without an order).
- Defamation
- Harming reputation with false statements — libel (written) or slander (spoken).
- Informed consent
- Agreement to care after understanding it; a competent resident may refuse.
- Advance directive
- A legal document stating care wishes if the resident can't speak (living will, DNR).
- DNR
- Do Not Resuscitate — do NOT perform CPR if the heart or breathing stops.
- Restraint checks
- Check the resident often (every 15-30 min); release/reposition about every 2 hours.
- Ethics of restraints
- Last resort, physician's order only, never for discipline or convenience.
- CNAs do NOT...
- Diagnose, assess, give medications, or perform sterile/invasive procedures.
- Telling a resident their diagnosis
- Refer it to the nurse — the CNA never gives a diagnosis or prognosis.
- Theft / misappropriation
- Taking a resident's property is illegal and reportable.
- Falsifying records
- Never chart care that wasn't done — it's illegal and dangerous.
- Chain of command
- CNA → LPN/LVN → RN → Director of Nursing → physician.
- CNA's immediate supervisor
- The nurse — report observations and concerns to the nurse first.
- Scope of practice
- Tasks a CNA is trained and legally allowed to do; observe, record, report.
- Delegation
- When a nurse assigns a task; the aide accepts only what's within scope and training.
- Refusing a delegated task
- A CNA may refuse an unsafe or out-of-scope task — and tell the nurse why.
- Nursing process (ADPIE)
- Assessment, Diagnosis, Planning, Implementation, Evaluation.
- CNA's part in the nursing process
- Carry out delegated implementation and report data — the nurse assesses.
- Care plan
- The team's written, individualized plan; the CNA must read and follow it.
- Speech-Language Pathologist (SLP)
- Helps residents with swallowing (dysphagia) and speech.
- Physical Therapist (PT)
- Helps with walking, transferring, and balance.
- Occupational Therapist (OT)
- Helps with dressing, eating, and daily tasks (ADLs).
- Registered Dietitian (RD)
- Plans special or therapeutic diets.
- Social Worker (MSW)
- Helps with emotional, financial, and discharge needs.
- Incident report
- A factual written record of an accident or unusual event.
- Reporting changes
- Report any change in a resident's condition to the nurse right away.
- Time management
- Prioritize by urgency and the care plan; ask the nurse if unsure.
- Confidential team communication
- Discuss residents only with the team, only on a need-to-know basis.
- Professional behavior
- Be punctual, dependable, respectful, and follow facility policy.
