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PCC Lecture > Exam 2 Modules 4-6 > Flashcards

Exam 2 Modules 4-6 Flashcards

1
Q

Layers of the CJM

A

o Layer 0: clinical decisions
o Layer 1: comprises the outcome = clinical judgement
o Layer 2: form, refine hypotheses; evaluation
o Layer 3: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes ▪ Not linear
o Layer 4: context (individual and environmental factors)

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2
Q

Components of CJM Layer 3

A

recognize & analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes

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3
Q

What do you include in shift report to oncoming nurse?

A

demographics, relevant med hx, current treatments, pt’s response to interventions, pending labs, procedures, current status, plan of care, concerns

Use I-SBAR-R

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4
Q

Assertive communication

A

SBAR, open, direct, honest, and non-judgmental

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5
Q

Passive vs Aggressive communication

A

Passive- I don’t count, you do.
Aggressive- I count, you don’t.

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6
Q

What is the primary purpose of the chart?

A

Communication

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7
Q

The EMR documentation system is problem oriented.
What are the patient issues an interdisciplinary team of professionals work on called?

A

Collaborative problem

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8
Q

What is charting by exception?

A

Chart only significant findings/exceptions to norms
Reduces charting time for nurses = more time w/ the pt
Omissions are the biggest problem

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9
Q

At what points do you triple check medications?

A

When pulling meds, before leaving med room, and at bedside before pt receives meds

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10
Q

Six Rights of Medication Administration

A

Right Drug
Right Dose
Right Route
Right Time
Right Patient
Right Documentation

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11
Q

Ways to enhance therapeutic communication

A

Address the pt, listen actively, establish trust, be assertive, interpret body language, use silence when appropriate, explore issues, validate feelings, clarifying statements, sit at eye level

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12
Q

Vulnerable populations

A

Homeless, poor, sexual orientation, mentally ill, physical disabilities, young, elderly, some ethnic and racial minority groups, gender

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13
Q

Are incident reports only for patients?

A

No. Can be for employees (ex: needle stick)

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14
Q

Do you reference incident report in the pt’s chart?

A

No

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15
Q

What do you include in incident report?

A

-Only state facts
-Do not place any blame
-Does not go in pt’s chart

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16
Q

Adverse event

A

An event in which care resulted in an undesirable clinical outcome

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17
Q

Near miss event

A

Caught before hand

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18
Q

Sentinel event

A

An event that results in death, permanent harm, or severe temporary harm

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19
Q

Examples of sentinel event

A

-Pt abduction
-Pt suicide
-A foreign body, such as sponge or forceps that was left in a patient after surgery
-A hospital operates on the wrong side of the patient’s body
-Hemolytic transfusion reaction involving major blood group incompatibilities

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20
Q

Documentation guidelines

A

Be clear and concise
Use correct terminology, spelling, and grammar
Timely
Signature

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21
Q

What time should be used when documenting?

A

The time the assessment/procedure was completed

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22
Q

Stereotype vs archetype

A

Archetypes- something recurrent, based on facts; usually not negative
Ex: eye or skin color based on region or geographic data

Stereotypes- Widely held unsubstantiated beliefs that have no basis in facts; negative beliefs
Ex: “Naturally athletic” “Naturally intelligent”

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23
Q

Discrimination

A

When a person acts on prejudice (stereotypes) and denies another person one or more of his/her fundamental rights
Ex: Not giving suspected drug user pain meds

24
Q

VORB

A

Verbal Order Read Back

In person

25
Q

TORB

A

Telephone Order Read Back

26
Q

What is the purpose of the read back component?

A

Avoid medical errors and ensure order accuracy

27
Q

Process for safe medication administration

A

-Know your patient history (HX, labs and assess your patient)
-Follow the orders
-Perform the Rights of Safe Med. Administration
-Triple check the medications against the MAR before the patient takes them
-Reassess your patient afterwards and document

28
Q

Ampule is a __________ dose only. Use __________ needle when drawing up medication to avoid chards of glass.

A

single; filter

29
Q

What type of needle must be used when drawing up insulin?

A

Insulin needle (orange) only because it is in units

Must be dual verified by another RN

30
Q

Can you give personal advice/opinion to pt’s and their families?

A

No

31
Q

How to enhance cultural awareness

A

Self assessment for bias and prejudices

32
Q

What is needed to deliver culturally competent care?

A

Cultural awareness and sensitivity

33
Q

What should you tell a trained interpreter before beginning any translations?

A

Advise them to translate everything that is said and leave nothing out

Be sure to use interpreter when obtaining consent

34
Q

How to complete a cultural assessment

A

-Open-ended questions
-Allow patient time to explain
-Listen with respect and remain non-judgmental

Advise pt you want to provide the best care by identifying their cultural practices

35
Q

I-SBAR-R

A

o Intro
o Situation
o Background
o Assessment
o Recommendation
o Read back

36
Q

Parameters for Nitroglycerin

A

-Check vitals before and after each dose
-1 SL tab every 5 minutes for a maximum of 3 doses
-Must wear gloves
-Make sure pt doesn’t take Cialis/Viagra or any other ED medications
-Warn pt before first dose about wicked headache
-Instruct pt to hold med under tongue, and not to chew-
-If patient’s HR is below 60 or Systolic BP (SBP) is less than 90 hold dose and notify HCP

37
Q

Should you give food with NSAIDs?

A

Yes. Upset stomach without it.

38
Q

How to administer ear drops for adults and kids

A

-Use solutions at room temperature – too cold leads to dizziness
-Pull pinna up and back for adults, down and back for children
-Push on tragus to instill meds

39
Q

Race is strictly related to

A

biology

40
Q

Potential violations of HIPAA

A

 Discussing pt’s in public areas
 Leaving charts out
 Not logging/locking computers
 Copying forms
 Social media

Providing shift report to oncoming RN does not violate HIPAA

41
Q

Cardinal rule of documentation

A

If it was not documented, it was not done

42
Q

How to correct an error in the chart

A

Strikethrough, write “mistaken entry”, date, and initial

Do not use whiteout

43
Q

Culturally competent model of care

ASKED

A

Awareness- Take an honest look at your own biases
Skills- Ability to conduct a cultural assessment with sensitivity
Knowledge- Information about cultural worldviews
Encounters- Takes practice to become competent
Desire- Must want to be culturally competent

44
Q

Insulin injections are

A

Subcutaneous (subq)

45
Q

General rules for subq injections

A

-Max. injection is 1 mL
-Sites include upper arm, abdomen, upper back, lower back, and top of thighs
-Rotate sites
-45-90 degree angle

46
Q

How should you draw up insulin?

A

Inject air into each vial first and then draw up regular (clear) insulin before long acting insulin (cloudy)

47
Q

General rules for intramuscular injections

A

-Z track method
-Max. injection is 1 mL to 5 mL depending on site
-Deltoid, Vastus Lateralis, and Ventrogluteal

48
Q

Max. injection & landmark for Deltoid is

A

1 mL

2 fingerbreadths below the acromion process in the middle third of the muscle

49
Q

Max. injection & landmark for Vastus Lateralis is

A

3 to 5 mL

Between greater trochanter and the lateral femoral condyle - injection site is the middle third of the muscle

50
Q

Max. injection & landmark for Ventrogluteal is

A

3 to 5 mL

Place your palm on the greater trochanter and thumb towards the groin avoiding the anterior superior iliac spine and iliac crest inject in the muscle

51
Q

When can PHI be released?

A

For payment, treatment, and normal healthcare operations

52
Q

What should be considered when administering the Albuterol?

A

-Check vitals before and after administering. Medication raises HR.
-Oral care
-If pt is unable to use hands, use a spacer.

53
Q

General rules for intradermal injections

A

-Max. injection is 0.1 mL
-5-15 degree angle
-Sites include forearms, upper chest, and upper back
-Ex: TB skin test

54
Q

Universals

A

values, beliefs, and practices that people from all cultures share

55
Q

Specifics

A

values, beliefs, and practices that are special/unique to a culture

56
Q

When do you document in the pt’s chart?

A

At the time of admission, transfer, discharge, ongoing care per policy, change in condition, communication

57
Q

MAR

A

Medication Administration Record

Comprehensive list of all ordered medications for pt

PCC Lecture (3 decks)

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