5 Written questions
5 Matching questions
- prescription pad
- nursing care plan
- long-term care unit dose system
- individual prescription order system
- Special documentation circumstances
- a prescriptions for patient's leaving hospital; presc given at clinics, outpatient surgeyr; additional info may be written "take with meals"; duration; pharmacies require patient's age and address on the presc
- b 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.
- c pt refuses med (thoroughly record incident and reason for refusal in nurses notes; notify dr; med error occurs
- d after initial data collection, this is done and this incorporates nursing diagnoses, critical pathway info, and physician-ordered and nursing-ordered care.
- e meds are dispensed from the pharmacy upon receipt of a prescription or drug order for an ind patient. Pharmacy sends supply of med ina bottle or box for patient, may hold 3-5 day supply. Meds are stored in med cabinet at nurse's station, med is removed as needed. ADVANTAGES: Review of prescription by nurse and pharmacist so greater patient safety; less chance for deterioration or expiration; easier inventory control; less chance for misuse by others; easier to charge patient; med is available for stat or prn usage. DISADVANTAGES: Frequent need to return or discard unused meds; complex ordering, preparing, administering, controlling, and recording systems required-time consuming
5 Multiple choice questions
- summary sheet; consent forms; physician's order form; H&P form; progress notes; critical pathways; nurses notes; lab tests record; graphic record; flow sheets; consultation reports; other diagnostic reports; MAR: PRN or unscheduled med record; case management; patient education record
- nurses record ongoing assessments of the patient's condition; responses to nursing interventions ordered by the physician or those initiated by the nurse; evaluations of the effectiveness of nursing interventions; procedures completed by other health professionals and other pertinent info such as physician or family visits and the patient's responses after these visits.
- Right patient, drug, time, dose, route and documentation
- althought the physician may order the correct dosage of the med, changes in the pt's status may require that the dosage be altered; the nurse must use the proper equipment, the proper drug form and the proper concentration; calculations must be right; check usual drug dosage
- depends on severity of effects on the pt; if due to carelessness or negligence of the nurse, the nurse may be held legally liable; repeated errors cannot be ignored
5 True/False questions
The right documentation → 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
floor or ward stock system → floor or ward stock system, ind presc. order system, unit dose system, automated dispensing system
progress notes → physician records frequent observations of the patient's health status on this
transcription → prescriptions for patient's leaving hospital; presc given at clinics, outpatient surgeyr; additional info may be written "take with meals"; duration; pharmacies require patient's age and address on the presc
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.