5 Written questions
5 Matching questions
- narcotic control systems
- Contents of patients charts
- medication administration record (MAR) medication profile
- progress notes
- standards of care
- a this is printed from the computerized patient database to ensure that the pharmacist and the nurse have identical medication profiles for the patient. This lists all meds to be administered
- b guidelines developed for the practice of nursing. These guidelines are defined by the nurse practice act of each state, by state and federal laws regulating health care facilities by JCAHO and by professional organizations such as the ANA and other agencies.
- c 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
- d physician records frequent observations of the patient's health status on this
- e 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.
5 Multiple choice questions
- 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
- 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
- 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.
- 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
- PRN medications are recorded on a separate MAR sheet referred to as this
5 True/False questions
physicians order form → 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.
computer-controlled dispensing system → 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
Kardex → as needed
individual prescription order system → 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
Guidelines for entries made on nurse's notes → 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.