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.

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Correct Answer is D

Explanation

To provide continuity of care.

A care plan conference is a meeting between the nursing home staff, the resident, and the resident’s family to set measurable, specific goals for the resident to meet during their stay, decide what needs to be done to meet those goals, and decide who in the nursing home is responsible for performing each job necessary to help the resident.The main purpose of this meeting is to provide continuity of care, which means ensuring that the resident receives consistent and coordinated care across different settings and providers.

Choice A is wrong becauseto discuss possible solutions to certain client problemsis not the main purpose of a care plan conference, although it may be one of the topics discussed.

A care plan conference is not meant to address only specific problems, but rather the overall plan of care for the resident.

Choice B is wrong becauseto evaluate the effectiveness of the care givenis not the main purpose of a care plan conference, although it may be one of the outcomes of the meeting.

A care plan conference is not meant to assess only the performance of the staff, but rather the progress of the resident.

Choice C is wrong becauseto gather information for the plan of careis not the main purpose of a care plan conference, although it may be one of the steps involved.

A care plan conference is not meant to collect only information, but rather to use it to develop and update the plan of care.

A. The client’s vital signs, oxygen saturation, and respiratory status. B. The client’s medical history, allergies, and current medications. C. The client’s nursing diagnosis, goals, and expected outcomes. D. The client’s family contacts, insurance information, and advance directives.

Correct Answer is A

Explanation

The client’s vital signs, oxygen saturation, and respiratory status.

This is because the admission nursing assessment is a comprehensive evaluation of the client’s physical, mental, emotional, and social status, as well as their current health problems and needs.

The admission assessment provides baseline data for comparison and planning of care.The client’s vital signs, oxygen saturation, and respiratory status are essential components of the admission assessment for a client who has pneumonia, as they reflect the severity of the infection and the risk of complications.

Choice B is wrong because the client’s medical history, allergies, and current medications are part of the health history interview, which is a component of the admission assessment but not the entire documentation.Choice C is wrong because the client’s nursing diagnosis, goals, and expected outcomes are part of the planning and implementation phases of the nursing process, which come after the assessment phase.Choice D is wrong because the client’s family contacts, insurance information, and advance directives are part of the administrative data collection, which is not directly related to the client’s health status or nursing care.

Normal ranges for vital signs vary depending on age, gender, and health conditions, but generally they are as follows:.

• 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: 95% to 100%.

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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:.

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Naxlex Comprehensive Predictor Exams

A nurse is participating in a care plan conference for a client who has multiple chronic conditions and complex care needs. What is the main purpose of this meeting?

Correct Answer is D

Explanation

A nurse is preparing to document the admission nursing assessment for a client who has pneumonia. Which of the following information should the nurse include in this documentation?

Correct Answer is A

Explanation

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.).

A nurse is reviewing the record system used in an agency. Which of the following types of records are used for documenting concise data about a client and making information quickly accessible to all health professionals? (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 documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

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

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:.