CNA certification exam guide: what's on it, how to register, and how to pass

After completing CNA training, one step stands between you and your state nurse aide registry listing: the state competency exam. This two-part test – a written knowledge section and a hands-on clinical skills evaluation – is how states verify that CNA graduates can safely perform direct patient care. Most candidates who prepare methodically pass on their first attempt.

Here is what the exam covers, how to register, what to expect on test day, and what your options are if you don’t pass.

At a glance: CNA state competency exam

What the NNAAP covers

The NNAAP was developed by the National Council of State Boards of Nursing (NCSBN). NCSBN no longer owns or develops the content – Credentia Nurse Aide LLC now owns and administers the program, and NCSBN directs all content and scheduling questions to Credentia. Around 20 to 30 states use the NNAAP, most of them with minor state-specific modifications.

The written examination is 70 multiple-choice items: 60 that count toward your score and 10 unscored pretest items being trialled for future exams. You cannot tell which is which, so treat every question as scored. You get two hours.

The content outline currently in force took effect in April 2024 and is built on Credentia’s 2019–2020 job analysis of working nurse aides. It has three major categories, each broken into subcategories with a published share of the exam. Those percentages tell you where to spend preparation time.

Nearly two-thirds of the written exam sits in one category, and basic nursing skills alone is more than a third of the whole test. If your study time is limited, that is where it belongs.

Category I: physical care skills

The largest category by a wide margin, and the one the skills evaluation draws from almost exclusively. It covers:

• Activities of daily living (22%): hygiene, dressing and grooming, nutrition and hydration, elimination, and rest, sleep and comfort
• Basic nursing skills (35%): infection control, safety and emergency response, therapeutic and technical procedures, and data collection and reporting. This single subcategory is the biggest block of questions on the exam. It is where hand hygiene technique, standard precautions and PPE, fall prevention, responding to choking, fire safety including the RACE and PASS mnemonics, and vital signs measurement all live.
• Self-care and independence (7%): range-of-motion exercises, positioning, ambulation, use of assistive devices, and supporting residents in doing as much for themselves as they safely can

The skills evaluation draws almost exclusively from this category. Every skill has a precise set of required steps – missing a “critical element” (such as performing hand hygiene before starting, or lowering the bed after repositioning) fails that skill outright, regardless of how well everything else goes.

Category II: psychosocial care skills

The smallest category at 10% of the exam, but the questions are not hard to prepare for and they are worth banking. It splits into:

• Emotional and mental health needs (8%): responding to behavioral expressions of dementia and cognitive impairment, understanding grief, loss, and end-of-life care, and supporting residents’ emotional wellbeing
• Spiritual and cultural needs (2%): supporting cultural, religious, and personal preferences in daily care

Category III: role of the nurse aide

At 26% of the exam, this category covers what CNAs are permitted to do, how they work with the rest of the team, and the legal boundaries of the role. Four subcategories:

• Communication (7%): effective communication with residents, families, and nursing staff, and reporting observations to the supervising nurse
• Client rights (8%): residents’ rights under federal law (OBRA 1987), privacy and confidentiality, and restrictions on the use of restraints
• Legal and ethical behavior (5%): scope of practice, supervision requirements, mandatory reporting of abuse, neglect and exploitation, and accurate documentation
• Member of the health care team (6%): working with physical therapists, occupational therapists, dietary and nursing staff, understanding care plans and care plan meetings, and professional workplace conduct

How to register for the CNA state exam

Step 1: confirm eligibility

You must complete a state-approved CNA training program before you can register for the exam. Your school or training program will typically issue a certificate of completion. Some states require the training program to submit completion records directly to the testing vendor – ask your program coordinator what the process is in your state.

Step 2: identify your state’s testing vendor

Vendor assignments change when state contracts are rebid, so verify yours rather than assuming. The main players:

• Credentia – administers the NNAAP in the largest number of states, through its CNA365 candidate portal. Pennsylvania, North Carolina, Colorado, Washington, South Carolina, and Northern California are among them.
• Prometric – administers nurse aide testing in Texas, New York, Florida, and a number of other states. In several of these, Prometric develops the state exam itself rather than delivering the NNAAP. New York is one: the state health department contracts with Prometric, which owns the New York competency examination.
• Other state-contracted vendors – some states use a different contractor entirely. California splits by region, using Credentia in the north and a separate contractor in the south, both under California Department of Public Health oversight.

Pearson VUE ran the NNAAP portfolio in the past and is still named as the vendor on a lot of older CNA advice. It is no longer the administrator – if a study guide tells you to register with Pearson VUE for your CNA exam, it is out of date.

Your training program should tell you which vendor administers the exam in your state. You can also check your state’s health department or nurse aide registry website, which is the authoritative source.

Step 3: create an account and register

Visit the vendor’s website and create a candidate account. You will need:

• Your legal name as it appears on your government-issued ID
• Your training program’s name and completion date
• A valid email address
• Payment for the exam fee

Most vendors allow you to select your preferred exam location and date during registration. Credentia handles this through its CNA365 portal, and Prometric has a scheduling tool on its website.

Step 4: wait for authorization

In some states, you must receive an Authorization to Test (ATT) letter before you can schedule your exam. This is issued after the testing vendor verifies your training completion. ATT processing takes 1–4 weeks depending on the state.

Step 5: prepare your ID

On exam day, you need two forms of ID: one government-issued photo ID (driver’s license, passport, state ID) and one secondary form with your name and signature. The name on both must match your registration exactly.

Test day: what to expect

Written (or oral) knowledge test

The written exam is delivered at a testing center or approved regional site run by your state’s vendor. Candidates who cannot read at a sixth-grade level, and candidates with documented disabilities, may request an oral version. The NNAAP oral form is also 70 items, with 10 of them reading comprehension questions in place of the written form’s pretest items.

On the NNAAP you receive 70 multiple-choice questions and two hours to answer them. Questions are scenario-based: you are given a situation involving a resident and asked what the correct CNA response is. There is no penalty for guessing, so answer everything. State-developed exams such as New York’s differ in length and timing – check your vendor’s candidate bulletin.

Time is rarely the binding constraint on the written section. Most candidates finish well inside the limit.

Clinical skills evaluation

The skills section is conducted separately, usually at a testing center equipped with a hospital bed, mannequin, and standard supplies. On the NNAAP you perform five skills in 30 minutes, and a trained evaluator scores each one satisfactory or unsatisfactory. All five must be satisfactory to pass.

The five are not fully random. Hand hygiene is always one of them. Of the four randomly selected skills, one is always a measurement skill – blood pressure, radial pulse, respirations, urine output, or weight. After you wash your hands the first time, the evaluator will tell you to simply state when you would wash your hands for the remaining skills rather than repeating the full procedure each time.

Each skill has a checklist with critical element steps that must all be performed, plus a cut score you have to reach on the remaining steps. Before and after every skill, you will be expected to:

• Introduce yourself and address the resident by name
• Explain what you are about to do
• Perform hand hygiene
• Ensure privacy and dignity
• Ask whether the resident needs anything else and place the call light within reach
• Return the resident to a position of comfort and lower the bed to its lowest position
• Report and record (verbally indicate you would chart the procedure)

These “wrappers” are critical elements. Missing them is grounds for failing the skill even if the technique itself was flawless.

Common testable skills include:

• Hand washing
• Indirect bed making / occupied bed making
• Nail care
• Denture care
• Mouth care for an unconscious or dependent resident
• Perineal care
• Catheter care
• Range-of-motion exercises (passive)
• Ambulating with a gait belt
• Transferring with a mechanical lift
• Measuring and recording vital signs (blood pressure, pulse, respirations, temperature)
• Measuring and recording weight
• Measuring and recording fluid intake and output

Pass rates and what they mean

There is no published national first-attempt pass rate for the CNA competency exam. Unlike the NCLEX, where NCSBN releases quarterly pass rates by candidate type and program, no federal agency and no testing vendor publishes an aggregate national figure for nurse aide testing. CMS does not collect one, and Credentia and Prometric do not release one. Any specific national percentage you see quoted on a test-prep site is an estimate someone has assembled, not an official statistic – treat it accordingly.

What is available is state-level and program-level data. Some state health departments and nurse aide registries publish pass rates for approved training programs in their state, and individual programs often share their own. Those are the numbers worth asking for, because they describe the pipeline you would be entering.

A pattern that does hold across state reporting: candidates fail the skills evaluation more often than the written test. The reason is structural rather than one of difficulty. The written exam is scored on a cut score across 60 counted items, so a handful of wrong answers is survivable. The skills evaluation requires all five skills to be rated satisfactory, and each skill has critical element steps that fail it outright if missed. One forgotten hand hygiene step ends a skill no matter how good the rest of the performance was.

When you are comparing training programs, ask for the program’s own pass rate and how recent it is. Programs with dedicated skills labs and supervised practice sessions before the exam tend to report stronger results.

Tips to pass the CNA exam

Written exam:

• Study the candidate handbook for your state – Credentia publishes a state-specific NNAAP handbook with the full content outline and the percentage of questions in each subcategory. Prioritize basic nursing skills, which is 35% of the written exam on its own, then activities of daily living at 22%.
• Practice with multiple-choice question sets from CNA prep books or online platforms. The question style is very specific: always ask what the CNA should do first, or what the appropriate response is to a specific resident situation.
• Pay attention to residents’ rights questions. OBRA 1987 created specific federal rights for nursing home residents, and these appear regularly on the exam.
• When in doubt, choose the answer that prioritizes resident safety and dignity.

Skills exam:

• Practice every testable skill until the procedure is automatic. You should be able to perform hand washing, gait belt transfers, and vital signs measurement without looking at a checklist.
• Narrate as you go. Talk through what you’re doing as if you’re speaking to the resident and evaluator simultaneously. “I’m going to perform hand hygiene before I begin…”
• Never skip the wrapper steps. The most common reason for skills failure is missing hand hygiene at the start or at the end, or forgetting to lower the bed and raise side rails.
• Practice in a space that resembles the testing setup – a table at bed height, a chair nearby, a basin and supplies within reach. Spatial familiarity reduces anxiety on test day.
• Take a skills practice session with a classmate or clinical instructor in the days before your exam.

What happens if you fail

Federal regulation sets a floor rather than a ceiling. Under 42 CFR 483.154, a state that caps the number of competency evaluation attempts may not set that cap below three, and candidates who fail must be told they have at least three opportunities. States are free to allow more. So “three attempts” is the minimum you are guaranteed, and your state may be more generous – check your state’s nurse aide registry rather than assuming three is the hard limit.

Separately, most vendors and states impose a window for completing both parts, commonly two years from your training completion date. That deadline comes from state program rules and the vendor’s candidate handbook, not from federal law. There is a 24-month period in the federal regulations, but it does something different: under 42 CFR 483.156, a state must remove you from the nurse aide registry if you perform no nursing or nursing-related services for 24 consecutive months, at which point you would need to test again.

Where a three-attempt cap does apply, exhausting it means repeating an approved training program before you can test again – and on the NNAAP you would then retake both parts, not only the one you failed.

If you fail one section on an attempt that is within your limit, you typically only need to retake that section. You can usually reschedule within a few weeks.

If you fail the skills section, request feedback from your testing vendor on which skills you failed and what steps you missed. Most vendors provide a score report that identifies the specific critical elements you did not complete. Use this to guide targeted practice before your next attempt.

State-by-state variation

The NNAAP provides a shared framework, but it is not universal and states that use it often modify it:

• Some states add state-specific questions about their own nursing home regulations
• Testing fees differ
• The number of skills tested in the clinical section is five on the NNAAP, but state-developed exams may test a different number
• Some states use an exam developed by their own contractor rather than the NNAAP, so the content outline and structure above may not apply
• Re-attempt limits and windows vary

Always verify your state’s specific requirements with your state’s nurse aide registry or health department. Your training program coordinator is usually the fastest source for current state-specific information.

After you pass

Once you pass both sections, your state will add your name to the nurse aide registry – the official database of state-certified CNAs that employers check before hiring. Registry listing is typically processed within 2–4 weeks of exam completion.

Staying on the registry depends on continuing to work. Federal rules require states to remove an aide who has performed no nursing or nursing-related services for 24 consecutive months, so most states run a renewal cycle on roughly that rhythm and ask you to document paid CNA employment. Many states also attach continuing education or in-service hours to renewal. The specific requirements vary, so check with your state registry well before your certification lapses – letting it expire generally means retesting.

For CNAs looking to move up the career ladder, CNA-to-RN bridge programs provide the most direct path to RN licensure, while CNA-to-LPN bridge programs offer a faster intermediate step. For a full picture of the credential and what CNAs do day-to-day, see the how to become a CNA guide.

References

1. Credentia, “Pennsylvania Nurse Aide Written (or Oral) Examination and Skills Evaluation Candidate Handbook” (representative NNAAP state handbook: 70-item written exam, two-hour limit, five-skill evaluation in 30 minutes, hand hygiene always included, critical elements and cut scores). https://credentia.com/storage/resources/pa-handbook.pdf
2. Credentia, “The 2024 National Nurse Aide Assessment Program (NNAAP) Written (Oral) Examination Content Outline,” effective April 2024, based on the 2019–2020 job analysis (three content categories and the percentage of the exam in each subcategory). https://kb-pa.credentia.com/en/article/the-2024-national-nurse-aide-assessment-program-nnaap
3. Credentia, “The Skills Evaluation” (NNAAP skills evaluation structure, scoring as satisfactory/unsatisfactory, and the requirement to pass all five skills). https://kb-pa.credentia.com/en/article/the-skills-evaluation
4. National Council of State Boards of Nursing (NCSBN), “NNAAP and MACE” (NCSBN developed the NNAAP but no longer develops or owns the content; Credentia now handles content and scheduling). https://www.ncsbn.org/exams/nnaap-and-mace.page
5. Prometric, “New York Nurse Aide” program page and New York State Nurse Aide Candidate Handbook (NYSDOH contracts with Prometric, which develops and owns the New York competency examination). https://www.prometric.com/exams/nurseaide-ny/
6. 42 CFR §483.152, “Requirements for approval of a nurse aide training and competency evaluation program” (75-hour minimum training, 16 hours supervised practical training). https://www.law.cornell.edu/cfr/text/42/483.152
7. 42 CFR §483.154, “Nurse aide competency evaluation,” subsection (f) (candidates must be advised of at least three opportunities; a state cap may be no less than three). https://www.law.cornell.edu/cfr/text/42/483.154
8. 42 CFR §483.156, “Registry of nurse aides” (removal from the registry after 24 consecutive months without performing nursing or nursing-related services). https://www.law.cornell.edu/cfr/text/42/483.156
9. Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87), “Nursing Home Reform Act — residents’ rights and nurse aide competency requirements,” Public Law 100-203. https://www.congress.gov/bill/100th-congress/house-bill/3545
10. California Department of Public Health, “CNA Testing Vendors” (California’s regional split between testing contractors under CDPH oversight). https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/CNA-Testing-Vendors.aspx
11. Texas Health and Human Services, “Nurse Aide Training and Competency Evaluation Program (NATCEP)” and “Nurse Aide Registry” (HHSC contracts with Prometric to administer the Texas competency examination). https://www.hhs.texas.gov/business/licensing-credentialing-regulation/long-term-care-credentialing/nurse-aide-registry
12. U.S. Bureau of Labor Statistics, “Nursing Assistants and Orderlies,” Occupational Outlook Handbook (certification and licensing overview; note the OOH wage figure lags the current OEWS release). https://www.bls.gov/ooh/healthcare/nursing-assistants.htm