5 Written questions
5 Matching questions
- history ad physical exam form
- physicians order form
- computer-controlled dispensing system
- Six Rights of Medictaion administration
- Drug administration resources
- a 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
- b 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
- c drugs books and cards; drug inserts; agency policy and procedure; pharmacist physician
- d Right patient, drug, time, dose, route and documentation
- e 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.
5 Multiple choice questions
- 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
- 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
- Reports of surgery, EEG, ECG, pulmonary function tests, radioactive scans and radiograph reports are usually recorded in this section of the patient's chart
- 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)
- 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.
5 True/False questions
Guidelines for entries made on nurse's notes → 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.
clinical decision-making support systems (CDSS) → pt refuses med (thoroughly record incident and reason for refusal in nurses notes; notify dr; med error occurs
PRN → 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.
nurse's notes and nurse history → 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.
unscheduled medication orders → PRN medications are recorded on a separate MAR sheet referred to as this