Pharmacology and Med Admin; Documentation and Infomatics Flashcards
The patient has an order for 2 tablespoons of Milk of Magnesia. How much medication does the nurse give him or her?
30mL
1Tb=15mL
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How does the nurse pull the patient’s ear when administering the medication?
upward and outward
Eardrops are administered with the ear positioned upward and outward for patients greater than 3 years of age.
A nurse is administering medications to a 4-year-old patient. After he or she explains which medications are being given, the mother states, “I don’t remember my child having that medication before.” What is the nurse’s next action?
Withhold the medications and verify the medication orders
(Do not ignore patient or caregiver concerns; always verify orders whenever a medication is questioned before administering it.)
A patient is transitioning from the hospital to the home environment. A home care referral is obtained. What is a priority in relation to safe medication administration for the discharge nurse?
Ensure that the home care agency is aware of medication and health teaching needs.
(A nursing responsibility is to collaborate with community resources when patients have home care needs or difficulty understanding their medications.)
The nurse is administering a sustained-release capsule to a new patient. The patient insists that he cannot swallow pills. What is the nurse’s next best course of action?
ask the presciber to change the order.
(Enteric-coated or sustained-release capsules should not be crushed; the nurse needs to contact the prescriber to change the medication to a form that is liquid or can be crushed.)
If a patient who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, the nurse suspects:
phlebitis
redness, warmth, and tenderness at the IV site are signs of phlebitis
A nurse accidently gives a patient a medication at the wrong time. The nurse’s first priority is to:
assess the PT for adverse effects
appropriate use of knowledge to manage and solve human problems, implies ethics, knowing why and why not, clinical judgement
wisdom
DIKW
Data-Information-Knowledge-Wisdom (DIKW) Pathway
The process of converting raw data into wisdom (used in all levels of nursing)
electronic medical record (EMR)
An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within ONE HEALTH CARE ORGANIZATION
EMR info can be part of the EHR
Electronic Health Record
An electronic record of health-related information on an individual that conforms to NATIONALLY recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across MORE THAN ONE health care organization.
Personal Health Record
An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled BY THE INDIVIDUAL
What are the “don’ts” of health documentation?
Don’t’s • Alter patient’s record • Write unacceptable abbreviations • Write imprecise descriptions • Chart ahead of time • Include opinion not facts
What are the “do’s” of health documentation?
- Correct chart
- Reflect nursing process
- Write legibly
- Conversation with MD
- Time patient was provided care
- Tell the whole story without garnishing it
- Late entry
- Watch your grammar, spelling, punctuation!
the medical record is
a legal document and req info describing the care that is delivered to a PT
It is also a financial record that serves as the basis for reimbursement
a nurse’s signature on an entry in a record designates
accountability for the contents of that entry
the major purpose of a handoff report is
to maintain continuity of care
Rounds allow nurses to
perform needed assessments, evaluate patients’ progress and determine the best interventions for a patient’s needs
A hospital information system consists of two major types of information systems:
CIS and administrative information systems.
On the nursing unit you are able to access a patient’s medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system?
electronic health record
A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE?
CPOE reduces transcription errors
You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet?
You need to use words the patients can understand when writing the directions.
While reviewing the pulmonary section of a patient’s electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient’s respiratory status in the nurse’s notes. The most likely reason for this is because:
The nurses were charting by exception.
(Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. No need for further documentation unless the pulmonary assessment changes & is no longer within normal limits.)
