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Test 2-Foundations in Nursing > Test 2 > Flashcards

Test 2 Flashcards

You may prefer our related Brainscape-certified flashcards:
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1
Q

CPOE

A

Computerized Provider Order Entry

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2
Q

POMR

A

Problem-oriented medical record

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3
Q

PIE

A

Problem, Intervention, Evaluation

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4
Q

APIE

A

Assessment, Problem, Intervention, Evaluation

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5
Q

SOAP

A

Subjective Data, Objective, data, Assessment, Plan

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6
Q

SOAPIE

A

Subjective Data, Objective, Data, Assessment plan, Invention, Evaluation, Revisions to plan

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7
Q

SOAPIER

A

Subjective data, objective data, assessment, Plan, Intervention, Evaluation, Revisions to plan

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8
Q

DAR

A

Data, Action, and Response

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9
Q

CBE

A

Charting by exception-records only abnormal or significant data.

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10
Q

EMR

A

Electronic Medical Record-one episode of care

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11
Q

EHR

A

Electronic Health Record-more than one episode of care

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12
Q

EHR documentation

A

Uses ADPIE to integrate nursing process into charging and it also allows information to be shared between medical staff

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13
Q

Flow Sheets

A

used to document routine care and observations

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14
Q

MAR

A

A list of ordered medications, along with dosages, routes, and times of administration

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15
Q

BCMA-Bar coded medication administration

A

a portable scanner scans the patient’s wrist band to get information

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16
Q

Kardex

A

Nonpermanent filing system for nursing records, orders, and patient information

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17
Q

Sentinal Event

A

A safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life

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18
Q

SBAR

A

Situation, Background, Assessment, and Recommendations. This is a standard hand off tool.

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19
Q

EBP

A

Evidence Based Practice-1. Clinical expertise, 2. pt values and needs, 3. Delivery of cost-effective health care.

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20
Q

Basic Research

A

Research conducted to generate theories

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21
Q

Applied Research

A

Testing theories in different situations with different populations

22
Q

Clinical Research

A

Conducted to test theories about the effectiveness of interventions

23
Q

Quantitative Research

A

Produces data in the field in the form of numbers

24
Q

Deductive Reasoning

A

Formulates a specific conclusion from a large amount of data.

25
Q

Descriptive Research

A

Identifies data and characteristics about the populations or phenomenon

26
Q

Correlational Research

A

Used to explore a relationship between two variables

27
Q

Experimental Research

A

Explores the causal relationships between variables

28
Q

Quasi-experimental research

A

Examines a causal relationship between variables, vut it may not meet the strict guidelines of experimental research.

29
Q

Qualitative Research

A

Based on a constructivist philosophy, which assumes that reality is composed of multiple socially constructed realities of each person or group. (data in words)

30
Q

Inductive Reasoning

A

Generalizes from specific facts

31
Q

Independent Variable

A

Concept or idea whose value determines the value of other (dependent) variables.

32
Q

Dependent Variable

A

The outcome that is affected by manipulation of the independent variable.

33
Q

Three A’s of Health Information

A
  1. Accurate
  2. Accessible
  3. Actionable
34
Q

Nursing Informatics

A

A specialty area of information that addresses the use of health information systems to support nursing practices.

35
Q

6 Rights of Patients

A

Right patient, right medication, right dose, right time, right route, and right documentation

36
Q

CDSSs

A

Computerized Clinical Decision Support Systems

37
Q

NMDS-Nursing Minimum Data Set

A

Represents the first attempt to standardize the collection of essential nursing data.

38
Q

ICNP-International Classification of Nursing Process

A

A standard terminology that provides a dictionary to describe and report nursing practices in a systematic way.

39
Q

Tactile Fremitus

A

Decreased or absent in patients with conditions that obstruct lung tissue, such as pneumothorax, tumors, pleural effusion, or COPD

40
Q

Adventitious Breath Sounds

A

Abnormal sounds that originate in the lungs and airways.

41
Q

S1

A

The sound of the mitral and tricuspid valves closing and marks the beginning of systole.

42
Q

S2

A

The sound of the aortic and pulmonic valves closing and marks the end of systole and the beginning of diastole.

43
Q

Pulse Deficit

A

present when the patient’s radial pulse rate is slower than the apical pulse rate because of cardiac contractions that are weak or ineffective at pumping blood to the peripheral tissues and extremities

44
Q

Cardiac Murmurs

A

Blowing or swishing sounds heard in systole or diastole caused by increased or abnormal blood flow through the valves of the heart

45
Q

Phlebitis

A

Inflammation of a vein, typically due to irritation, often from IV solutions or infections

46
Q

S/S’s of Arterial insufficiency

A

5 P’s; Pain, pallor, pulselessness, paresthesia (numbness or tingling), or paralysis

47
Q

Neurogenic Bladder (bladder paralysis)

A

The inability of the bladder to empty (bladder is unable to fully contract because of impaired nerve innervation

48
Q

Paralytic Ileus

A

paralysis due to lack of peristalsis

49
Q

Borborygmi

A

Intestinal tract is overstimulated or has increased motility, hyperactive bowel sounds

50
Q

Stenosis

A

Harding of the arteries, which creates a bruit or “swooshing” sound

51
Q

Rigidity (involuntary tightening)

A

Caused by conditions such as peritoneal inflammation, appendicitis or acute cholecystitis

52
Q

Ascites

A

An abnormal accumulation of fluid in the peritoneal cavitiy

Test 2-Foundations in Nursing (1 decks)

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