A nurse is preparing to report a change in a client’s condition to another health care provider.

What should the nurse include in the report?

A summary of all the interventions performed since admission.

A description of how the nurse feels about the client’s situation.

A comparison of the client’s condition with other similar cases.

A statement of facts, changes, trends, and responses to treatment.

Answer and Explanation

The Correct Answer is D

A statement of facts, changes, trends, and responses to treatment. This is the best way to report a change in a client’s condition to another health care provider because it provides clear, concise, and relevant information that can help with decision making and continuity of care.

Choice A is wrong because a summary of all the interventions performed since admission is too broad and may not reflect the current situation of the client.

Choice B is wrong because a description of how the nurse feels about the client’s situation is subjective and may not be helpful for the other health care provider. Choice C is wrong because a comparison of the client’s condition with other similar cases is not specific to the individual client and may not account for differences in factors such as age, comorbidities, or preferences.

Normal ranges for vital signs, laboratory values, and other parameters may vary depending on the source and the context, but some common examples are:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

• Oxygen saturation: greater than 95%.

• Blood glucose: 4.0 to 7.8 mmol/L (72 to 140 mg/dL).

• Hemoglobin: 13.5 to 17.5 g/dL for males, 12.0 to 15.5 g/dL for females.

• White blood cell count: 4.0 to 11.0 x 10^9/L.

• Platelet count: 150 to 400 x 10^9/L.

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Correct Answer is C

Explanation

Medication administration record.

A medication administration record (MAR) is a document that records the medications that have been given to a patient, including the dose, route, time, and nurse’s initials.

A MAR is an essential part of nursing documentation and ensures safe and accurate medication administration.

Choice A is wrong because a graphic record is a document that shows the trends of vital signs, intake and output, weight, and other measurements over time.

A graphic record does not include information about medications.

Choice B is wrong because a daily care record is a document that records the routine care activities that have been performed for a patient, such as hygiene, nutrition, elimination, mobility, and comfort measures.

A daily care record does not include information about medications.

Choice D is wrong because a client teaching record is a document that records the education that has been provided to a patient or family, such as disease process, medications, diet, exercise, self-care, and discharge planning.

A client teaching record does not include information about medication administration.

CBE documentation is a method of charting by exception that allows the nurse to document only those findings that fall outside the standard of care or norms defined by a specific institution.

CBE documentation reduces the amount of time required to document care and eliminates unnecessary or redundant information.

However, CBE documentation does not apply to medication administration, which must be documented accurately and completely for every patient.

A. Use standardized terminology and abbreviations. B. Enter data as soon as possible after providing care. C. Share login information with other authorized users. D. Review and verify data before saving or submitting. E. Correct errors by drawing a single line through them.

Correct Answer is ["A","B","D"]

Explanation

Choice A is correct because using standardized terminology and abbreviations can improve the clarity, accuracy, and consistency of the documentation in an EHR system.

• Choice B is correct because entering data as soon as possible after providing care can ensure the timeliness, completeness, and validity of the information in an EHR system.

• Choice C is wrong because sharing login information with other authorized users can compromise the security, privacy, and integrity of the EHR system.HIPAA guidelines require that each user has a unique identifier and password to access the EHR system.

• Choice D is correct because reviewing and verifying data before saving or submitting can prevent errors, omissions, and discrepancies in the EHR system.

• Choice E is wrong because correcting errors by drawing a single line through them is a method used for paper records, not electronic records.Electronic records should have a mechanism to track changes and corrections without altering the original data.

:HIPAA Guidelines for Electronic Medical Records:Electronic Health Records - Health IT Playbook.

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A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

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Naxlex Comprehensive Predictor Exams

A nurse is using CBE documentation for a client who has diabetes mellitus. The nurse administers insulin to the client and documents this on a:.

Correct Answer is C

Explanation

A nurse is using an electronic health record (EHR) system to document the care provided to a client who has pneumonia. The nurse should follow which of the following guidelines when using an EHR system ? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

What is one advantage of using a computerized system for documentation and reporting?

A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

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A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

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A nurse is preparing to report a change in a client’s condition to another health care provider.

What should the nurse include in the report?