5 Written questions
5 Matching questions
- The right route
- unscheduled medication orders
- incident report form
- The right documentation
- consultation reports
- 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 PRN medications are recorded on a separate MAR sheet referred to as this
- c each institution has their own form and procedure for completing the form; purpose of the form is for follow-up by the RIsk Management department (Is this an incident that can lead to litation?); this form never goes in the pt's chart.
- d the order will specify the route; never substitute one route for another; the nurse must be knowledgeable about the preferred route of a med (affects absorption, some meds are painful IM so IV is preferred); document injection site on chart
- e When other physicians or health professionals are asked to consult on a patient, the specialist's summary of findings, diagnoses, and recommendations for treatment are recorded in this section
5 Multiple choice questions
- look at results (response to drug, therapeutic effects, adverse effects)
- medication errors can result in serious complications known as this, 7000 death in hospitals annually from this
- grants permission to the health care facility and physician to provide treatment.
- physician on admission to the hospital interviews the patient and given this which lists the problems to be corrected, often referred to as the H&P
- gives the patient's name, address, date of birth, attending physician, gender, marital status, allergies, nearest relative, occupation and empooyer, insurance carrier and other payment arrangments, religious preference, date and time of admission to the hospital, previous hospital admissions and admitting problem or diagnosis.
5 True/False questions
laboratory tests record → is an example of manual recording of temp, pulse, resp and bp. Pain assessment nka the 5th vital sign can also be recorded on this.
physicians order form → administer if needed
THe right time → the order will specify time; hospitals have policies that determine which hours meds will be given when they are ordered; such as daily (be familiar with the policy), to be effective many meds be given on a rigid schedule; often has to be planned around pt's schedule; meals; drug interactions; one time only for emergency meds (check to see if med has already been given, document immediately, prn meds should be charted immediately)
Contents of patients charts → When other physicians or health professionals are asked to consult on a patient, the specialist's summary of findings, diagnoses, and recommendations for treatment are recorded in this section
The right patient → ask the pt's name as you are checking the bracelet, errors may occur on a busy unit; at risk for errors: pediatric pt, geriatric pt, non english speaking pt, confused or critically ill pt; nursing home patients ay not be wearing a bracelet