5 Written questions
5 Matching questions
- The right documentation
- Special documentation circumstances
- computer-controlled dispensing system
- What is included in the safe preparation and administration of the drug?
- a notation on chart should be made ASAP after administering; parenteral; MAR; progress notes. CAUTION: Never record meds that you did not give or record meds before they are given; never give med prepared by another nurse; you cannot assume that all of the rights were followed unless you do it yourself
- b Drug Distribution Systems, interpreting Dr's orders, documentation; three checks, six rights, handling controlled substances; helpful resources
- c newer system for med ordering an administration is this that is supplied by the pharmacy daily, stocked with single-unit packages of medicines. Nurse uses a security code and password, thumb print
- d nurse makes a professional judgment on its acceptability and safety of drug order, including type of drug dose and dose preparation, therapeutic intent, route potential allergic reactions or contraindications
- e pt refuses med (thoroughly record incident and reason for refusal in nurses notes; notify dr; med error occurs
5 Multiple choice questions
- check the drug name; similar names; check expiration date; know the drug action, read label 3 times (before removing the drug from the shelf, before preparing or measuring the actual prescribed dose before replacing drug on shelf or before administration)
- Paper system; narcotic/controlled substances is delivered to the unit and signed for by RN and she verifies that meds are all there and in good condition before signing; kept locked in specified cabinet; narcotic keys are carried by nurses and turned over to the next shift when narcotics are counted; at end of each shift, narcotics are counted, inventoried by 2 nurses one from oncoming shift and one from ending shift; narcotics are signed out as they are used.
- is an adaptation of the system used in the acute care setting. This is designed with ind drawers to hold one resident's med containers for 1 week. Drawer is labeled with the resident's name, room #, pharmacy name and telephone number and name of the health care facility.
- 1. completing records, including vital signs, immediately ater making contact with and assessing of the patient, that is when first admitted or returning from a diagnostic procedure or therapy. 2. recording all PRN medications immediately after administration and the effectiveness of the med. 3. Changes in a client's status and who was notified. 4. Treatment for a sudden chang in a client's status. 5. Transfer, discharge or death of a client.
- also referred to as integrated care plans, care or clinical maps and clinical trajectories, this document is a comprehensive standardized plan of care that is individualized at admission by the physician and nurse case manager. It describes a multidisciplinary plan used by all caregivers to track the ind's progress toward expected outcomes within a specified period.
5 True/False questions
floor or ward stock system → all but the most dangerous or rarely used meds are stocked at the nursing station in stock containers. This system has been used most often in very small hospitals and hospitals where there are no charges directly to the patient for meds such as in some government hospitals. Advantage to this is readily available meds and fewer inpatient prescription orders and minimal return of meds. Disadvantages are: increased potential for med erros because of large array of stock meds from which to choose and lack of review by pharmacist; increased danger of unnoticed passing of expiration dates and drug deterioration; jeopardizing of patient safety; economic loss caused by misplaced or forgotten charges and misappropriation of med by hospital personnel; increased amounts of expired drugs to be discarded; need for larger stocks and frequent total drug inventories; storage problems on the nursing units in many hospitals
Evaluation → look at results (response to drug, therapeutic effects, adverse effects)
nursing care plan → after initial data collection, this is done and this incorporates nursing diagnoses, critical pathway info, and physician-ordered and nursing-ordered care.
consent form → grants permission to the health care facility and physician to provide treatment.
laboratory tests record → provides a means of documenting the health teaching provided to the patient, family, or significant others and includes statements regarding the learner's mastery of the content presented