5 Written questions
5 Matching questions
- medication orders
- nurse consequence for med error
- clinical decision-making support systems (CDSS)
- critical pathways
- unscheduled medication orders
- a CPOE is supported by this
- b 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.
- c 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
- d PRN medications are recorded on a separate MAR sheet referred to as this
- e client's full name; date and time of order, drug name; drug dosage; route of administration and specific directives; time and frequency of adminstration; duration of order for outpatient; sig of physician or health care provider ordering drug
5 Multiple choice questions
- all procedures and treatments are ordered by the health care provider on this form which include general care, lab tests to be completed, other diagnostic procedures, and all medications and treatments such as physical therapy or occupational therapy.
- floor or ward stock system, ind presc. order system, unit dose system, automated dispensing system
- 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
- Durg Distribution System, interpreting dr's orders, documentation, three checks, six rights, handling controlled substances, helpful resources
- a large index-type card usually kept in a flip-file or separate holder that contains pertinent info such as the patients name, diagnosis, allegies, schedules of current medications with stop dates, treatments and the nursing care plan.
5 True/False questions
standards of care → indicates that a med is to be given for a specified number of doses. Ex. cefazolin 1 g q6h x 4 doses. or until said time
The right route → 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
flow sheets → 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.
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
computerized prescriber order entry (CPOE) → 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