Documentation and Reporting Flashcards
7 cards from real QMA INSULIN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation and Reporting flashcards as text
A resident refuses insulin at 0800. What must the QMA document in the medication administration record (MAR)?
Answer: Record the refusal, reason if given, and notify the nurse
Refusals must be documented on the MAR with the reason if known, and the nurse must be notified promptly.
When documenting insulin administration, which blood glucose value would require the QMA to withhold the dose AND document a parameter hold?
Answer: 58 mg/dL
A blood glucose of 58 mg/dL is below typical hold parameters (usually <70 mg/dL), requiring the dose to be withheld and documented accordingly.
Which element is REQUIRED in every insulin administration entry on the MAR?
Answer: Time, dose, site, and initials of the QMA
Every MAR entry must include the time, dose administered, injection site, and the QMA's initials as a legal record.
A QMA notices the previous shift's insulin entry has no initials. What is the appropriate action?
Answer: Report the incomplete entry to the charge nurse
Incomplete documentation by another staff member must be reported to the charge nurse rather than altered by the QMA.
What is the correct procedure if a QMA makes a documentation error on the MAR?
Answer: Draw a single line through the error, initial, and date it
Errors are corrected by drawing a single line through the mistake, then initialing and dating — this preserves the original entry for legal purposes.
After administering insulin, a resident develops shakiness and diaphoresis. What must the QMA document FIRST?
Answer: Observed signs and symptoms, time of onset, and actions taken
Signs of hypoglycemia after insulin must be documented immediately, including symptoms observed, time, interventions, and nurse notification.
The pharmacy delivers a new insulin pen for a resident. Before administering from the new pen, the QMA should verify and document which of the following?
Answer: That the pen matches the resident's name, insulin type, and concentration on the MAR
The QMA must verify and document that the pen label matches the resident's name, prescribed insulin type, and concentration before administration.
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