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 ["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.

A. Inform the client that he cannot leave without a physician’s order. B. Explain the purpose and benefits of the cardiac catheterization to the client. C. Assess the client’s understanding and readiness for discharge. D. Notify the physician and the charge nurse about the client’s request.

Correct Answer is C

Explanation

Assess the client’s understanding and readiness for discharge.

This is the first action that the nurse should take because it allows the nurse to evaluate the client’s mental status, coping skills, and educational needs.

The nurse should also explore the reasons why the client wants to go home and address any concerns or fears that the client may have.

Choice A is wrong because it is not client-centered and may increase the client’s anxiety or anger.

The nurse should not threaten or coerce the client to stay in the hospital against his will.

Choice B is wrong because it is not the priority at this time.

The nurse should first assess the client’s knowledge and willingness to undergo the cardiac catheterization before providing information about it.

Choice D is wrong because it is not the first action that the nurse should take.

The nurse should notify the physician and the charge nurse after assessing the client and documenting the findings.

A cardiac catheterization is a procedure that uses a thin, flexible tube (catheter) to access the heart and blood vessels.It can help diagnose and treat various heart conditions, such as coronary artery disease, heart valve disease, congenital heart defects, or heart failure.

Some of the benefits of cardiac catheterization are:.

• It can provide detailed information about the structure and function of the heart and blood vessels that other tests may not show.

• It can help determine the best treatment plan for the client based on his or her specific condition and needs.

• It can deliver treatments such as angioplasty, stent placement, valve repair or replacement, or device implantation during the same procedure.

• It can reduce the need for more invasive surgery or repeated hospitalizations.

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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 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

Correct Answer is C

Explanation

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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:.