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306 test 2


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copy deck
anything written/printed that can be used as record or proof for authorization
Permanent document of all information relevant to health care
non governmental or legal agency/professional organization that gives recognition to an institution
people that look at medical record and check to see if it meets the standards
utilization review
Nursing Documentation must be: ACFCTSO
Accurate, Concise, Factual, Complete, Timely, Specific, Organized
a confidential, permanent legal documentation of information relevant to a patients health care
Medical Record
how is the patient's needs and progress communicated?
through progress notes and nurse's notes
an effective way to learn the nature of an illness and the patients response is to read the medical record
objective and subjective data are:
exact, precise, concise, spelling, and abbreviations
thorough communication
timely immediate documentation
logical order
the nurse is documenting on the client's record and notes that she made an error. The action that the nurse should take is to:
Draw a straight line through the error and initial it
Client is wheezing and experiencing some dyspnea on exertion. This is an example of
The P of PIE
patients chart is organized so that each discipline has a section
Source Records
used to eliminate redundancy, ensure concise documentation of routine care, emphasize abnormal findings, and identify trends in care
Charting by exception
the case manager advises nursing staff on specific nursing care issues, coordinates the referral to services provided by other disciplines, and ensures client education is completed
Case Management
tool used in managed care that incorporates the treatment interventions from all disciplines.
critical pathways
allow quick and easy assessment of patient status
Flow Sheets and graphic record
provides current orders, treatments, and diagnostic testing that are ongoing
Client care summary or KARDEX
provides a method of determining the hours of care and staff required
Acuity recrd
preprinted, established guidelines that are used to care for patients with similar health problems
standardized care plan
discharge summary -- discharge planning begins when?
on admission
Recording a nurse's description of the teaching provided to the client on performance of self medication administration is found in a:
discharge summary form
can an LPN take a telephone order?
given mass dissolved in a known volume
a client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic medication. the nurse recognizes that which is accurate?
a parenteral route is the route of choice -parenteral=intradermal, subQ, intramuscular, intravenous
intradermal angle
15 degrees
how is insulin administered?
what would a patient who's toxic on morphine look like?
respiratory depression and decreased urinary output
synergistic effect
two meds combines better than 1
proprietary patent (good for how long?)
good for 7 years
the body's action on drugs -absorption -distribution -metabolism -excretion
the drug's action on body
the nurse is teaching the client how to prepare 10 units of regular insulin and 5 units of NPH insulin for injection. The nurse instructs the client to:
inject air into both vials and withdraw the regular insulin first
a client has an order for 30 U of U-500 insulin. The nurse is using a U-100 syringe and will draw up and administer:
u-500 insulin is 5 times as strong as u-100 insulin. 30 units of u-500 insulin = 6
must be a documented Dx, condition, or indication for each medication ordered
responsible for filling prescriptions accurately and for being sure prescriptions are valid
responsible for knowing what medications are prescribed, their therapeutic and nontherapeutic effects, and the associated nursing implications
standing orders
til dr. changes it or has stop order
prn orders
as needed
single orders
only once
stat orders
stock supply
historical, medications are available in large multidose containers
unit dose
current system, uses portable carts containing 24 hour supply of patients medications
computer controlled
automated medicine dispensing systems used primarily for narcotics
six rights
right medication, right dose, right client, right route, right time, right documentation
tetrogenetic effect
adverse affect on fetus
how do you recognize a nurse statement that reflects the scientific method?
"The client doesn't look the same today. I think something is wrong."
during an admission history you have a client that has trouble breathing at night. in obtaining data for a problem-oriented database, the nurse should first question the client about:
the onset and duration of his present breathing problem
when a 53 yr old client is seen at the clinic for a yearly physical exam, that evaluating the client's weight, the nurse also considers the age and height.
comparing data with normal health patterns.
what is the long term goal for a tailor who is admitted for eye surgery?
returning to sewing
perferred injection site for a 1 year old
how much time does it take for regular insulin to take effect?
2-4 hours
how would you interpret ii gtts OD?
two drops to the right eye
how would you calculate a medication order from 80mg/tsp to the correct amt of ml
where do you inject heparin?
medications used to wash out a body cavity delivered with a stream of solution
the primary source of data for elevation is the:
when a client-centered goal has not been met in a projected time frame, the most appropriate action would be to:
repeat the entire sequence of the nursing process to discover needed changes
to find out what's real and what's truth
scientific method
using info to develop a solution
problem solving
determine health status from patient's symptoms
diagnostic reasoning and inference
drawing a conclusion based on pieces of evidence
clinical decision making
three parts of a diagnosis
1. nanda 2. related to 3. as evidenced by
skills that are necessary of a nurse
1. interpretation-assess 2. analysis-critiquing 3. evaluation-assessing results 4. inference-considering alternatives 5. explanation-presenting arguments 6. self regulation-reflecting on experiences and how to improve
five types of nurse levels
1. novice 2. advanced beginner 3. competent 4. proficient 5. expert
a systematic and scientifically based process used by nurses to identify and make decisions about client needs
a series of steps or acts that leads to accomplishment of some goal or purpose
friggin PROCESS
to provide individualized, holistic, safe, quality, effective, and efficient care to clients
purpose of a nursing process
systematic data collection, validation, and interpretation
components of critical thinking
1. specific knowledge base 2. experience 3. competencies 4. attitudes 5. standards
Maslow's Hierarchy of basic human needs is a:
common method of selecting priorities
Leinninger's sunrise model
culturally congruent care
connecting patient caring
personal experience; 5 nursing competencies
systems model: we are a system of parts, all parts important, if one part goes wrong, the whole system is affected; primary, secondary, tertiary care
nursing diagnosis
to tell you why you need to do the things in your care plan
care plan
to-do list
gather data
subjective=what the patient says; what can't be measured objective=measurable
drug names
1. generic -- official name 2. chemical 3. trade -- pharmaceutical co has a patent of the name
meds have 3 classifications
1. systemic 2. organ 3. symptom
medication formed determines:
route of administration and there are 20 diff. forms
#1 reason for toxic effects (accumulation of a med beyond therapeutic index):
hydration level
what affects circulation?
hypertension in diabetes

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