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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Focus charting is a method of organizing health information in an individual’s record that centers on the patient’s concerns and strengths.It uses a three-column format to document the data, action and response (DAR) of each focus.

The advantages of using focus charting are:.

• It highlights the client’s concerns and strengths, which makes the care more patient-centered and holistic.

• It reduces redundancy and duplication of data, as it avoids repeating information that is already recorded in other forms or flow sheets.

• It facilitates communication among health care team members, as it promotes interdisciplinary documentation and helps organize the information in a concise and precise way.

Choice D is wrong because focus charting does not incorporate nursing diagnoses and care plans, although it is based on the nursing process.Nursing diagnoses and care plans are documented separately or as part of the action category.

Choice E is wrong because focus charting does not provide a chronological record of events, but rather organizes the data by the focus.A chronological record of events can be found in other forms of documentation, such as narrative or SOAP notes.

A. Include factual information about what happened. B. State opinions about who was responsible for the error. C. File the report in the client’s medical record. D. Notify the risk management department. E. Discuss possible solutions to prevent future errors.

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

Explanation

The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.

Choice B is wrong because the nurse should not state opinions about who was responsible for the error.

This could be seen as biased, unprofessional or accusatory.

The nurse should focus on the facts and the causes of the error, not on blaming individuals.

Choice C is wrong because the nurse should not file the report in the client’s medical record.

This could violate the client’s privacy and confidentiality.

The report should be filed in a separate system that is accessible only to authorized personnel.

Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.

This could be premature, unrealistic or inappropriate.

The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.

View Question and Answer

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

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:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is using focus charting to document a client’s progress notes. What are the advantages of using focus charting? (Select all that apply.).

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

Explanation

A nurse is documenting an incident report for a medication error that occurred on her unit. Which of the following actions should the nurse take? (Select all that apply.).

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

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.).

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is using an electronic health record (EHR) system to document care for a client who has pneumonia. Which of the following is an advantage of using an EHR system?

A nurse is using a computerized documentation system in a health care facility. Which of the following actions should the nurse take to ensure confidentiality and security? (Select all that apply.).

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

A nurse is giving a change of shift report to the nurse on the next shift. Which of the following statements by the nurse is appropriate for handoff communication?

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

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:.