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:.
Graphic record.
Daily care record.
Medication administration record.
Client teaching record.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I read back the order for a chest x-ray for Mr. Jones in room 20.”.
This is the best way to verify a telephone order from a radiologist, as it ensures that the nurse has accurately transcribed the order and that the radiologist has confirmed it.
Reading back the order also allows the nurse to clarify any doubts or questions about the order, such as the urgency, the reason, or the patient’s condition.
Choice A is wrong because it does not verify the order, but simply repeats it.
The nurse should not assume that the order is correct without confirmation from the radiologist.
Choice B is wrong because it asks the radiologist to repeat the order, which is inefficient and may cause confusion or errors.
The nurse should repeat the order to the radiologist, not the other way around.
Choice C is wrong because it uses a closed-ended question that can be answered with a yes or no, which may not reflect the radiologist’s true intention or understanding of the order.
The nurse should use an open-ended statement that requires the radiologist to acknowledge or correct the order.
According to federal regulations and accreditation standards, verbal and telephone orders should be authenticated by the prescriber within a specified time frame, usually 24 hours.Some states may have different or more stringent requirements, so nurses should be familiar with their state laws and regulations.Verbal and telephone orders should also be documented and signed by two nurses or one nurse and one enrolled endorsed nurse for verification and administration.
Correct Answer is A
Explanation
Daily weight, blood pressure, and pulse.
A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc.A flow sheet is useful for clinical communication and tracking the patient’s condition over time.A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time.A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them.A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.
These documents are not part of a flow sheet.
Choice B is wrong because a MAR is not a flow sheet.
Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.
Choice D is wrong because a discharge planning and referral summary is not a flow sheet.
Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition.However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration.Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children.Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.