Before providing care, the nurse reviews the client's pertinent history, daily treatments, diagnostic procedures, allergies, problems, and other information. Which form should the nurse review to learn all of this information?
1. The client's medical record
2. The MAR (medication administration record)
3. The written care plan
4. The Kardex
Correct Answer: 4
Rationale 1: The medical record contains this type of information, but the complete chart is lengthy and would take the student more time to review.
Rationale 2: The MAR includes only those medications that are prescribed or scheduled to be administered during the client's stay. It would not include other information like diagnostic tests, daily care, and so on.
Rationale 3: The written care plan may be utilized, but there is another more effective option available.
Rationale 4: The Kardex is a concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. The system is on either an index-type file or a computer-generated form. Information is usually organized into sections: client history/information, list of medications, IV fluids, daily treatments and procedures, diagnostic procedures, allergies, how the client's physical needs are met (type of diet, bathing needs, etc.), and a problem list with stated goals.
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