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Medical Office Procedures > Module 4 > Flashcards

Module 4 Flashcards

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USMLE® Step 1 flashcards
1
Q

The use of the term ”client-care unit “ is used to more accurately reflect the language used in the hospital and other health care facilities.

A

F

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2
Q

Routine hospital admissions are referred to as elective.

A

T

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3
Q

Often a patient admitted for surgery will be admitted the morning of surgery.

A

T

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4
Q

The provincial health insurance plan ( OHIP ) covers semi-private accommodation.

A

F

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5
Q

If Jeff has only standard accommodation coverage and he is admitted to a semi-private room because there is no other, Jeff will have to pay the difference.

A

F

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6
Q

patient admitted to hospital will have only one hospital number ( MRN ) which will remain the same for all admissions to that hospital.

A

T

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7
Q

The admission sheet will contain an account number that is the same number as the hospital number.

A

F

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8
Q

Never let anyone enter information on a form that is not labelled.

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9
Q

The head nurse on the unit is responsible for creating a patient’s chart on admission and disassembling it on discharge.

A

F

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10
Q

“Old charts” ( paper ) are retrieved from Medical Records ( Health Information Services ).

A

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11
Q

The admission sheet records a patient’s provisional diagnosis.

A

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12
Q

The provisional diagnosis may differ from the actual diagnosis.

A

T

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13
Q

If you need to contact someone to make a decision about the patient’s medical care when the patient is unable to do so , you must contact the patient’s next of kin.

A

F

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14
Q

The person assigned the “power of attorney relating to health-care decisions “ is the next-of-kin.

A

F

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15
Q

In a manual environment the care plan is called a Kardex, and it is a separate entity from the chart.

A

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16
Q

DAR charting refers to Date, Assessment, and Revision.

A

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17
Q

Charting by Exception means that only essential information is charted.

A

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18
Q

SOAP charting stands for Subjective assessment, objective assessment, assessment, plan.

A

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19
Q

When using voice activation software for transcribing dictated reports, a transcriptionist must edit the report before it is added to the chart.

A

T

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20
Q

In a manual environment, the administrative assistant would add an intake/output sheet to the post-operative chart.

A

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21
Q

Every time a chart leaves the floor ( unit ) it is the responsibility of the clinical secretary to keep a written record of where it went, using an outguiding system

A

T

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22
Q

A patient transfer occurs whenever a patient is moved from one hospital to another facility.

A

F

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23
Q

A terminal cleaning of the bed and other furniture used by a patient is done 2x per week.

A

F

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24
Q

I f a nurse calls in sick on a unit it may be the responsibility of the clinical secretary to find a replacement from a staffing list.

A

T

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25
Q

A hospital policy manual includes visiting hour policies, and policies related to the use of electrical equipment.

A

T

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26
Q

The ability to process orders manually is no longer a necessary skill for the clinical secretary.

A

F

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27
Q

Orders are typically written by the hospitalist.

A

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28
Q

When checking physicians’ orders which you are unsure about, it is better to deal with a grumpy physician than with an inaccurate order.

A

T

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29
Q

Orders related to assessments, treatments, and direct patient care are recorded on a
Kardex in a manual environment.

A

T

30
Q

Vital signs include: temperature, pulse, respirations, and blood pressure.

A

T

31
Q

Intake and output are automatically activated for any patient on parenteral therapy.

A

T

32
Q

Occasionally an anaesthetist and a surgeon will both write orders for postoperative
analgesics for the same client. You should implement both sets of orders.

A

F

33
Q

NPO means nil per os ( nothing by mouth )

A

T

34
Q

A soft/surgical soft diet is one low in fibre.

A

T

35
Q

the suffix “ ostomy” means creation of an artificial opening.

A

T

36
Q

In medical terminology, activities of daily living include reading, watching TV, eating, and
sleeping.

A

F

37
Q

BR with BRP’s means up ad lib.

A

F

38
Q

To prevent bedsores , patients who cannot move about in bed must be turned or
repositioned every 4 to 6 hours.

A

F

39
Q

On admission, Dr. Salisbury takes the patient’s doctor order sheet, which has not had the
patient’s essential information recorded on it as yet, saying, “ I have patients waiting. I will just
write the orders and then you can fill in the patient name and essential information.” Which of
the following is the best response?
a. “Just a minute while I go ask the nurse if that is OK.”
b. “That is fine, Dr. Salisbury. Just put the order sheet in this pile when you are
finished.”
c. “That is against hospital policy. I will get to the chart in a few minutes. You are
welcome to go see your patients and come back.”
d. “I am sorry Dr. Salisbury, but I need to fill in the required information before you
write the orders. I will do it right now and then we won’t have to worry about the
order sheet ending up on the wrong patient’s chart.”

A

D

40
Q

All medications given to a patient must be recorded and signed for. Several sheets may be used
to record different types of medications. Which of the following are examples of some names
for separate medication sheets(MARs or cMARS) used to record medications?
a. Routine medications, anticoagulants medications and PRN medications.
b. Patient controlled analgesia, blood pressure medications, and potassium supplements.
c. Antinauseants, antidiarrheals, blood pressure medications, and antiarrhythmics.
d. Single dose medications, hypoglycemic medications, antiarrhythmics and antibiotics.

A

A

41
Q

41.When you are selecting a echart by entering the patient’s last name and first initial , a
number of possible names come up. What is the clinical secretary’s responsibility at this point?
a. Ask the nurse to deal with the situation.
b. Pick the name that seems most reasonable.
c. Compare the client’s date of birth and health number to the available selections.
d. Go to the patient’s room and ask for identification to prove who they are.

A

C

42
Q

Which of the following is the best way to describe the purpose of a “risk management
program”?
a. It reduces the risk of visitors acquiring a severe infection.
b. It aims to improve staff and patient safety and reduce the risk of litigation.
c. It ensures that all patients will avoid the risk of having to stay in the hospital for
longer than expected.
d. It requires the nursing staff to lift patients safely and be assigned two patients at a
time.

A

B

43
Q

Which of the following best describes a consultation report?
a. A report generated when the nurse consults with a physician.
b. A report generated when an internist consults with a cardiologist.
c. A report generated when the physiotherapist consults with an occupational
therapist.
d. A report generated when all health professionals meet for a patient conference.

A

B

44
Q

What would be the best response in the following situation? Dr. Jones wrote an order in the
morning and signed the order sheet. You processed that order and sent the duplicate order
sheet to pharmacy. He came in again in the evening and wrote other orders, but just added
them to the original order rather than sign again.
a. Ask the nurse to process the order.
b. Disregard the order as it has not been documented correctly.
c. Tell Dr. Jones that he should know better than that and that you intend to report
him.
d. Report the discrepancy to the nurse who will follow up with the physician.

A

D

45
Q

Which of the following would you most likely find on the Kardex or patient intervention screen
of a surgical patient under the heading of teaching and emotional support?
a. Diet as tolerated
b. Commode by bedside
c. Ambulate with assistance
d. Coughing and deep breathing q2hr.

A

D

46
Q

Which of the following orders would you process first?

a. Daily FBS
b. Lasix 20 mg IV stat
c. Out of bed with assistance this evening
d. Demerol 50 mg Atropine 0.6 mg IM one hour before surgery

A

B

47
Q

Which of the following is the best interpretation of the statement “the IV went interstitial and it
had to be removed.”
a. The IV fluid bag went dry and had to be discontinued.
b. The needle dislodged from the vein and had to be removed.
c. Air invaded the closed intravenous system and the IV had to be removed.
d. The IV catheter became clogged with a clot and the system had to be discontinued.

A

B

48
Q

Which of the following would be the best interpretation of the Doctor’s order “ flush saline lock

q4hrs. ”
a. Change the IV tubing every 4 hours
b. Run the IV at a faster rate every 4 hours.
c. Add medications to the intravenous bag every 4 hours.
d. Run normal saline through the IV catheter every 4 hours.

A

D

49
Q

Which of the following is the best interpretation of the Doctor’s order “ IV D5W TKVO”?

a. Total vein obstruction has occurred.
b. Keep IV volume over the minimal amount.
c. Dextrose and water at a rate the client can tolerate.
d. IV, five percent dextrose and water running at a minimal rate to keep the vein open.

A

D

50
Q

Which of the following is the best description of how to record an IV solution in an electronic
environment?
a. Write “copied” and your signature on the Doctor’s order sheet.
b. Record the name of the intravenous solution to be infused on the paper MAR.
c. Click the appropriate options from the IV management section on the PI screen.
d. Do not record anything on the PI screen. That is the nurse’s responsibility.

A

C

51
Q

Which of the following is an example of an implanted IV port?

a. It is ideal for continuous intravenous infusion.
b. It allows easy access for administering blood and blood products.
c. It allows for medication to be injected through the skin into the catheter.
d. It allows the catheter to be inserted less invasively than a peripheral angiocath.

A

C

52
Q 
Which of the following people/departments would you call if a patient on your unit did not
receive a meal tray?
a. Admissions
b. The team leader
c. Nutritional services
d. The clinical coordinator
A

C

53
Q

Which of the following is the best example of a high-fiber diet?

a. Meat, fish, eggs and milk
b. Fish, fried food, whole grains and meat
c. Cabbage, lean meat, stewed fruit, and whole grains
d. Pasta, white bread, boiled chicken, and well-cooked beef

A

C

54
Q

Mr. Blair is booked for surgery and a general anaesthetic at 0800 tomorrow. At what time will
the NPO order be implemented?
a. From midnight this evening
b. At 1800 hours this evening
c. At 2200 hours this evening
d. From supper this evening until he goes to the OR.

A

C

55
Q

For which of the following patients is the Doctor most likely to order enteral foods ?

a. A patient who is vomiting with the flu.
b. A patient who has had major abdominal surgery.
c. A patient who had had a stroke and is dysphasic.
d. A patient who has been booked for a colonoscopy.

A

C

56
Q

Which of the following would be a good food choice for someone on a gluten-free diet?

a. Oatmeal cereal
b. Bran muffins
c. Blueberries
d. Bread pudding

A

C

57
Q

Mr. Blair returned to the unit from the recovery room, where he was stabilized following bowel
surgery. The post-op order says to carry out an abdominal assessment every shift until
peristalsis returns. How will the nurse go about carrying out that order?
a. He will book an abdominal ultrasound once a week.
b. He will palpate the abdomen for distention once a shift
c. He will listen to the patient’s abdomen with a stethoscope once a shift
d. He will give the patient a drink and listen for the stomach to growl once a shift

A

C

58
Q 
Where would an order that reads “ Gravol suppository 50 mg for nausea q4h prn” be
transcribed?
a. The TPR graph
b. The progress notes
c. The interdisciplinary notes
d. The MAR or cMAR and the Kardex
A

D

59
Q

Which of the following is the best description of what a hypotonic bladder is like?

a. The bladder is full of urine.
b. The bladder has lost its tone or strength.
c. The bladder has developed excess tone.
d. The bladder has a residual urine of 50 cc.

A

B

60
Q

Mrs. Jones has a Doctor’s order to obtain an MSU. Which of the following is the best description
of a MSU?
a. Mrs. Jones will collect an early morning urine specimen.
b. Mrs. Jones will collect all of her urine for a 24 hour period.
c. Mrs. Jones will urinate in a paper cup then pour a small amount of the urine into a
sterile test tube.
d. Using sterile technique, Mrs. Jones will begin to void, stop midstream, collect a
sterile sample and continue voiding.

A

D

61
Q

Which of the following tests would most likely be ordered to detect a residual urine?

a. A midstream urine to check the urinary sphincter
b. A cystoscopy to see how much urine is in the bladder
c. An abdominal xray to estimate whether bladder tone is lost
d. A post-void catheterization to see how much urine is left in the bladder

A

D

62
Q

Which of the following is the best description of a continuous bladder?
a. A closed sterile system, usually using a three-way catheter.
b. A straight catheter irrigated with normal saline four times a day
c. An indwelling catheter to straight drainage placed in the bladder and irrigated every
morning
d. A bulb syringe is used to flush out the bladder and tubing PRN

A

A

63
Q

Which of the following therapies would a physiotherapist most likely be responsible for?

a. Oxygen therapy
b. Ventilation therapy
c. Medication administration
d. Coughing and deep breathing

A

D

64
Q

Which of the following interventions require that a specific consent be signed?

a. Spirometry
b. Thoracocentesis
c. Sputum specimen
d. Inhalation therapy

A

B

65
Q

Dr. Atwood has written an order to suction Mr. Little prn. What supplies would you order from
Central Supply for the nurse to carry out this order?
a. A size 25 catheter
b. A tracheostomy tube
c. A sterile bundle for catheterization
d. French-scale catheter, connecting tubing and a portable suction machine.

A

D

66
Q

Which of the following orders would you enter onto the Kardex or PI screen as preparation for a
patient who has been booked for a cardiac catheterization on January 10th?
a. NPO starting at 2200 January 9th. Groin prep early AM January 10th.
b. NPO starting at 1200 January 9th. Groin prep 1800 on January 10th.
c. Clear fluids on January 9th. Bed rest January 9th and 10th. Groin prep prn.
d. DAT January 8th and 9th. Groin prep prn. Bed rest January 10th.

A

A

67
Q

What do nurses often do a half hour before they get a patient up post-surgery in order to
reduce the discomfort?
a. Provide a warm bath to relax the muscles
b. Provide relaxing music for the patient to listen to.
c. Medicate the patient to make the experience more comfortable.
d. Discuss complications that have been experienced by patients who did not get up
after surgery.

A

C

68
Q

Which of the following is the best explanation for the standard procedure to reposition
immobile patients at least every 2 hours?
a. Patients need the emotional stimulation of repositioning.
b. Repositioning prevents tissue hypoxia and breakdown
c. Patients are more compliant to treatment if they are repositioned
d. Family members will be more satisfied with the care the patient is receiving.

A

B

69
Q

Which of the following measurements must be reported when ordering a pair of anti-embolic
stockings from central supply?
a. Height and weight
b. Weight and any mobility issues
c. The diameter of the leg and the client’s height
d. The diameter of the calf and thigh and the length of the legs.

A

D

70
Q

Which of the following is the best explanation of the use of a trapeze bar?
a. It keeps the patient from sliding down in bed
b. It lifts a patient who is too heavy out of bed into a chair.
c. It is used for a patient to grab onto in order to exercise, position themselves and get
up.
d. It is placed between the patient’s legs post hip surgery to keep them apart.

A

C

Medical Office Procedures (4 decks)

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