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Normal adult resting BP is roughly systolic 90-120 and diastolic 60-80 mmHg, per AHA fundamentals. Below 90/60 may indicate hypotension and risk of falls or hypoperfusion; readings of 130/80 or above are stage 1 hypertension per the 2017 AHA/ACC guidelines, and a reading at or above 180/120 with symptoms is hypertensive crisis requiring urgent evaluation. CNAs measure accurately and report findings outside the resident's set parameters to the nurse promptly so timely intervention can occur.

AHA technique: 5-minute quiet rest, back supported, feet flat (not crossed), arm bare and supported at heart level, appropriate cuff size (bladder length 80% of arm circumference, width 40%), and no talking during measurement. Cuff placed over clothing (d), unsupported arm hanging at the side (c), and routine standing measurement (b) all introduce systematic error. Wrong technique can over- or under-estimate BP by 10-20 mmHg, leading to misdiagnosis, missed hypertension, or unnecessary treatment.

The radial pulse is the standard for routine adult vital signs—accessible, comfortable, and reliable. Carotid (a) is used in emergencies for adults and may cause a vagal response when both sides are compressed; femoral (d) is used in code situations or vascular checks; pedal/dorsalis pedis (c) checks lower-extremity circulation. Count for 30 seconds and multiply by two if the rhythm is regular; count a full 60 seconds if the rhythm is irregular or when an apical-radial deficit check is needed.

Normal adult respirations are 12-20 breaths per minute at rest. Bradypnea (<12) may indicate opioid effect or neurologic compromise; tachypnea (>20) may indicate fever, pain, hypoxia, or respiratory distress. CNAs count without telling the resident (to avoid altered breathing pattern), watch one full minute (or 30 seconds if regular), and note depth and effort. Report abnormal findings to the nurse.

Awareness of being observed alters the natural respiratory pattern, causing the resident to breathe faster, slower, or deeper. Best practice: keep fingers on the radial pulse after counting pulse and continue to count respirations covertly, observing chest rise and noting depth, rhythm, and effort. Announcements (c), instructions to alter pattern (d), and breath-holding (b) all produce inaccurate readings. Accurate respiratory rate is a sensitive early indicator of deterioration in sepsis, pneumonia, and cardiac compromise.

Normal oral temperature is approximately 97.0-99.0°F (36.1-37.2°C); axillary readings run about 1°F lower, while rectal readings run about 1°F higher. Fever per CDC and CMS guidance is a reading at or above 100.4°F (38.0°C), an important infection sign in elders, who may not show classic febrile presentations and may instead present with confusion or weakness. CNAs report any fever, hypothermia (below 95°F), and any acute temperature change immediately to the nurse for evaluation and possible workup.

Oral temperature is unsafe or inaccurate in unconscious, confused, seizure-prone, oxygen-mask, mouth-breathing, or post-oral-surgery residents. Alternative routes (axillary, temporal, tympanic) should be used. Recent hot/cold intake (a) merely requires waiting 15-30 minutes; brief activity (c) similarly resolves with rest. Choosing the wrong route can cause injury or significantly inaccurate readings.

For verbal cognitively intact adults, the 0-10 numeric scale or Wong-Baker FACES (useful for limited literacy or language barriers) is standard. PAINAD (a) is for advanced dementia; FLACC (b) is validated for infants/young children; Glasgow (d) measures consciousness, not pain. Pain assessment is the 'fifth vital sign'; CNAs report pain levels and reassess after analgesic intervention by the nurse.

I&O monitoring uses graduated containers and milliliter measurement to track fluid balance—important in CHF, renal disease, dehydration, post-op care, and tube feedings. Includes oral fluids (water, juice, ice chips counted as half-volume), IVs, tube feeds, and outputs (urine, emesis, drainage, liquid stool). Estimates (d), partial recording (c), or combined totals (b) lose the data needed for nursing assessment and medical decisions.

Fowler's position (45-60° HOB elevation) supports breathing, eating, and aspiration prevention by reducing reflux and using gravity to keep the airway protected. Semi-Fowler's (30-45°) is common for tube feeding and during and after meals; high Fowler's (60-90°) maximizes lung expansion for residents with dyspnea. Supine (d) is flat on the back; prone (c) is flat on the stomach; Sims' (a) is semi-prone left lateral with knees flexed and is used for enemas. Position changes every two hours protect skin from pressure injury.

Per NPUAP/EPUAP guidelines, prevention requires turning at least every 2 hours, off-loading heels (pillow under calf, not under heel itself), keeping skin clean and dry, using pressure-redistribution mattresses, and maintaining nutrition/hydration. Prolonged single position (d) causes ischemia; massaging reddened areas (b) damages capillaries; doughnut cushions (a) concentrate pressure on a ring and worsen tissue damage.

Occupied bed making protects safety and dignity: raise bed to working height (ergonomics), keep one rail up to prevent falls, drape the resident with a bath blanket (privacy/warmth), turn the resident to the far side, roll/fan-fold soiled linen, place and tuck clean linen, then roll resident over the linen ridge to the clean side. Lowering both rails (c), forceful pulling (a), and climbing on bed (d) are unsafe.

Position the wheelchair on the resident's strong side at about 45° to allow weight bearing through the stronger leg during the pivot. Lock wheels, raise footrests, and apply a gait belt for control. Wheelchair on the weak side (b) forces weight on the affected leg and risks fall; behind the bed (a) or across the room (d) is not reachable and increases shear/falls. Always use the strong limbs to lead and weight-bear.

PROM is performed by the CNA when the resident cannot move the joint independently—common after CVA, contracture risk, or sedation. Move slowly through normal range, never force past pain, support above and below the joint to prevent injury. Active ROM (a) is done by the resident; resistive (c) is therapy-led; therapist presence (b) is not required for daily PROM, which is a CNA care-plan task once trained.

Eye care during bathing: use water only (no soap), wipe from inner canthus (near nose) outward to avoid contaminating the nasolacrimal duct, and use a separate clean corner of the cloth for each eye to prevent cross-contamination. Outer to inner (b) risks pushing debris into the duct; same cloth (d) cross-contaminates; soap (a) irritates eyes. Eyes are always done first when the cloth is cleanest.

Female perineal care uses front-to-back strokes (clitoris/urethra → vagina → anus), changing to a clean section/cloth for each stroke, to prevent fecal organisms (E. coli) from entering the urethra and causing UTI. Back-to-front (a) directly promotes UTI; circular motions (b) and reused cloths (c) similarly spread contamination. UTI is a leading source of hospitalization in elders—proper technique is preventive care.

Unconscious oral care: position side-lying or with head turned to allow drainage, use oral swabs lightly moistened (chlorhexidine per protocol), keep mouth open with a padded device, have suction ready, never pour liquids that could be aspirated. Supine brushing (a) and pouring fluids (b) cause aspiration pneumonia; skipping care (c) leads to dry mucosa, ulcers, and ventilator-associated pneumonia. Oral hygiene every 2-4 hours is standard.

Dentures are fragile and expensive to replace. Line the sink with a towel or partially fill with water to cushion a possible drop; use a denture brush and denture cleaner (not abrasive toothpaste, which scratches the acrylic), rinse in cool or lukewarm water (hot water warps the plate), and store in a labeled container filled with water or cleaning solution when out of the mouth, because drying also causes warping. Hot water (c), dry brushing (a), and dry storage (d) damage dentures and risk loss.

Diabetic neuropathy hides injury; ulcers and amputation risk are high. Daily inspection (mirror or assist), lukewarm water (hot water burns), thorough drying between toes (prevents fungal infection), moisturize tops/soles but NOT between toes, properly fitted shoes and socks, no barefoot walking. CNAs in California do NOT cut diabetic or anticoagulated toenails—this is delegated to nurse/podiatrist. Hot soaks (a), curved cutting (c), and barefoot walking (b) cause injury.

Rule: 'Weak in, strong out.' Dress the affected side first—the limb has limited range and pulling sleeves over it is easier when the garment is loose; undress the affected side last for the same reason. Dressing strong side first (a) leaves no room for the weak side. Forcing independence (c) ignores capability; restricting to gowns (b) violates dignity. Always assist with the affected limb supported.

Aspiration precautions: upright at 90° (high Fowler's), chin tuck reduces aspiration risk, small bites and slow pace, follow ordered thickness (nectar/honey/pudding), avoid mixing textures, alternate solids/liquids if ordered, keep upright at least 30 minutes after meals. Lying flat with chin up (a) opens the airway; straws (d) can cause uncontrolled bolus; eating while walking (c) is unsafe. Aspiration pneumonia is a leading cause of death in dysphagia.

Clean-catch midstream technique: cleanse the meatus front-to-back to reduce skin/fecal contaminants, void initial stream into the toilet to flush the distal urethra, catch a 30-60 mL midstream sample in a sterile container, finish in the toilet, cap, label, and send promptly or refrigerate. No cleaning (a), first-stream collection (d), or scooping from the toilet bowl (b) produce contaminated specimens that lead to misdiagnosis and unnecessary antibiotic treatment.

Bedpan technique: explain, provide privacy, raise HOB slightly (Fowler's-like), roll resident to side, position pan against buttocks, roll back onto it. Use a fracture pan (shallow front edge) for hip-fracture or limited-mobility residents to minimize lifting. Forceful sliding (c) shears skin; prolonged sitting (b) causes pressure injury; standard pan with hip injury (d) requires harmful repositioning. Clean immediately after use and provide hand hygiene.

Prompt incontinence-associated dermatitis (IAD) prevention: cleanse with pH-balanced perineal cleanser (not harsh soap that strips skin), pat dry (no friction), apply barrier cream/zinc ointment as ordered, change linens, reposition. Leaving in soiled brief (b) causes IAD, pressure injury, and is neglect. Harsh soap (a) damages skin barrier; baby powder (d) cakes in skin folds, harbors bacteria, and is inhalation hazard. Document time, amount, and characteristics.

Continence programs use scheduled/prompted voiding (every 2-3 hours), adequate fluids (1500-2000 mL/day unless contraindicated), pelvic floor exercises (Kegels) if cognitively able, monitoring and positive reinforcement. Fluid restriction (c) concentrates urine and causes UTI and dehydration; routine catheterization (b) is prohibited unless medically necessary (CMS F-690) due to CAUTI risk; relying on briefs alone (d) abandons continence goals and violates 42 CFR §483.25(e).

Mealtime is care: sit at eye level (signals respect and unhurried presence), offer choices, small bites paced to the resident's swallowing rhythm, alternate textures, verbal cues ('here is your soup'), observe for coughing or pocketing. Standing over (d) is disrespectful and rushes; mixed food (a) is unappetizing and culturally inappropriate; distracted feeding (c) is unsafe and disrespectful. Document intake percentage and any difficulties.

Sims' position: left lateral semi-prone with the right (upper) knee and hip flexed forward, left arm behind the body, head turned. Used for enemas, rectal medications, perineal procedures, and to redistribute pressure. Supine (a), prone (d), and high-Fowler's sitting (c) serve other purposes. Reposition every 2 hours and check pressure points; do not maintain Sims' for prolonged periods due to shoulder and hip pressure.

Mechanical lifts require two trained staff: assess weight limit, choose correct sling size, attach all loops to corresponding hooks, raise just enough to clear the surface, guide rather than push (resident swings), lock all wheels, communicate each step to resident. Operating alone (c) violates safe-patient-handling standards; ignoring weight limit (a) can drop the resident; speed (d) increases swing and injury. Sling type matches need (full-body, toileting, ambulating).

Safe ambulation: walk slightly behind and to the side, grasp the gait belt underhand at the back (better leverage and control), match the resident's pace, watch for fatigue. If a fall begins, ease the resident to the floor while protecting the head—holding them upright risks both the resident and CNA injuring spines. Walking ahead pulling (d) tugs off-balance; hand-holding alone (b) gives no control; pushing (c) is unsafe and undignified.

Normal adult resting heart rate is 60-100 beats per minute. Bradycardia (below 60) may be normal in athletes or may signal heart block, beta-blocker effect, or vagal stimulation; tachycardia (above 100) may indicate fever, pain, anxiety, dehydration, hemorrhage, hyperthyroidism, or a primary cardiac issue. CNAs report rates outside the resident's individualized parameters and any abnormal rhythm (irregular, weak, thready) to the nurse promptly. Count for a full 60 seconds when the rhythm is irregular for accuracy.

Normal SpO2 on room air is 95-100% for most adults; 90-94% may indicate mild hypoxia and warrants closer monitoring; below 90% is significant hypoxia requiring immediate evaluation and possible supplemental oxygen. Some chronic COPD residents have a baseline of 88-92% and may have a physician-set lower target to avoid suppressing hypoxic drive. Report values outside the resident's individualized parameters to the nurse. Probe placement, motion, nail polish, cold extremities, and poor perfusion can falsely lower the reading.

Lateral position with appropriate pillow support relieves sacral/heel pressure (alternative to supine in the q2h turning schedule), maintains spinal alignment, and prevents hip adduction (pillow between knees) and shoulder compression (top arm pillow). Bad positioning without supports increases trochanter pressure and shoulder strain. Distractors (a, c, d) describe harms that proper technique prevents. Always check skin at pressure points each turn.

Apical pulse is auscultated with a stethoscope at the 5th intercostal space, midclavicular line (left, over the apex of the heart). Counted for a full 60 seconds. Used for infants, irregular rhythms, before digoxin administration, and when peripheral pulses are weak. Wrist (c) is radial; popliteal (d) is behind the knee; temple (a) is temporal. CNAs check apical for accuracy when the radial is irregular or weak.

Accurate weights require consistency: same time of day, same scale, similar clothing, after voiding, with the scale calibrated. Significant changes (≥3 lb in 24 h, ≥5 lb in 7 days, or any unexplained loss) suggest fluid shifts (CHF, dehydration) or nutritional concerns and must be reported. Hospice residents are still weighed per care plan unless comfort indicates otherwise. Distractors (a, b, d) introduce error or omit important monitoring.

Supine: lying flat on the back. Risks include sacral and heel pressure injury, aspiration if HOB low, and back pain. Mitigations: small pillow under head, small support under knees (do NOT fully bend knees long-term—causes contractures), heel float to off-load heels, reposition every 2 hours. Prone (c) is face-down; high-Fowler's (d) is upright; Sims'/lateral (a) is side-lying. Position choice depends on medical condition and care plan.

Stool collection: use a clean dry bedpan or toilet specimen 'hat' to keep stool free of urine and toilet water (both can invalidate testing). Transfer a portion (about 1 tablespoon for routine; more for ova/parasites) using a tongue blade into the labeled container, cap, and send promptly per order. Wear gloves. Contamination (c, d) invalidates testing; bare hands (b) violate Standard Precautions. Document time, characteristics (color, consistency, blood).

Sputum is best collected early morning before eating/drinking/brushing because overnight secretions are most concentrated. Rinse mouth with water (not antibacterial mouthwash, which can alter culture), have the resident take 3-4 deep breaths and then cough from deep in the lungs (saliva is not sputum). Send promptly. Other timings (a, b, d) reduce yield or introduce contamination. Document amount, color, consistency, and odor.

Tympanic technique: apply a clean disposable probe cover, gently pull the pinna up and back for adults (down and back for children under 3) to straighten the ear canal, insert the probe snugly aimed at the tympanic membrane, activate, and wait for the audible/visual signal. Forceful insertion (d) risks ear injury; no cover (a) is unhygienic; cheek (c) measures skin, not core. Cerumen and incorrect aim affect accuracy.

AROM: resident performs the movements independently, maintaining strength, flexibility, and joint health. PROM: CNA moves the joint when the resident cannot. AAROM (active-assistive) is a middle option. The benefits include prevention of contractures, maintenance of circulation, and preservation of function. Distractors (b, c, d) misdescribe the concept; AROM is everyday activity-based or scheduled, not requiring physicians or lifts.

Coughing, choking, wet/gurgly ('wet') voice after swallowing, pocketing food, drooling, and unexplained weight loss are red flags for dysphagia and aspiration risk—the resident needs swallow evaluation (SLP) and likely diet modification. Several days of refused meals signal a clinical change requiring nurse assessment. Normal eating behaviors (b, c, d) are not concerning. Aspiration pneumonia is a leading cause of death in elders with dysphagia; timely reporting saves lives.