Nurs- B260 Fundamentals Exam 2 Questions with Complete Solutions
Medical Record - Correct Answer Purpose:
-Facilitate interdisciplinary communication, provide a record of care, allow for auditing, monitoring, and evaluation of care provided. Also serve as sources of research data and learning resources -Used for communication, legal documentation, reimbursement for health care services, auditing and monitoring (to see if standards of care were met) Guidlines for Quality Documentation - Correct Answer -Factual -Accurate -Complete -Current -Organized
Narrative - Correct Answer Method of documentation:
-used to record patient assesment and nursing care provided. Uses story like format to document the information
SOAP - Correct Answer Method of documentation:
subjective, objective, assesment, plan
PIE - Correct Answer Method of documentation:
problem, intervention, evaluation Focus Charting (DAR) - Correct Answer Method of documentation: data, action, response Problem Oriented Medical Record - Correct Answer Method of documentation: places primary focus on patients individual problems- data bases, problem list, care plan, progress notes Charting by Exception - Correct Answer shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes 1 / 2
Within defined limits - Correct Answer WDL Within normal limits - Correct Answer WNL Document every call - Correct Answer You should ________ made to a provider
Patient's 5 Rights - Correct Answer Right:
-patient -drug -dose -time -route Check for Allergies - Correct Answer Before giving any drug, you always ______ medication reconciliation - Correct Answer A procedure to maintain an accurate and up-to-date list of medications for all patients between all phases of health care delivery.Allergic - Correct Answer (Monitoring adverse reactions) -monitor by asking any current allergies and comparing ingredients of other medications Anaphylaxis - Correct Answer (Monitoring adverse reactions) -immediate medical attention is required Toxic - Correct Answer (Monitoring adverse reactions) -develop after a prolonged intake of a med or when it accumulates in the blood due to impaired metabolism or excretion; some antidotes are available to treat certain types of this Idiosyncratic - Correct Answer (Monitoring adverse reactions) -patient overreacts or underreacts to a medication; or has a reaction different than normal (benadryl in kids- get hyper instead of tired)
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