Quiz 2

Question 1

nursing proccess: steps of the nursing process

Answer 1

assess
- gather information about the client’s condition
diagnose
- identify the client’s problem[s]
plan
- set goals of care and desired outcomes and identify appropriate nursing actions
implement
- perform the nursing action identified in planning
evaluate
- determine if goals were met and if outcomes were achieved

Question 2

nursing process: sources of data collection

Answer 2

primary source
- the pt. who is awake and oriented
- most of the information comes from this source
secondary source
- i.e. spouse, family, medical record, other healthcare professionals

Question 3

nursing process: interpreting and analyzing data collection

Answer 3

clustering information into groups using a logical sequence
comparing information to standards of care
identifying patterns that the information hold
make a conclusion about what the information means

Question 4

nursing process: actual nursing diagnosis

Answer 4

regards a human response

i.e. nutritional imbalance

Question 5

nursing process: risk nursing diagnosis

Answer 5

a human response that may occur

i.e. risk for fall

Question 6

nursing process: health promotion diagnosis

Answer 6

pt. wants to improve their well-being

i. e. smoke cessation

Question 7

nursing process: subjective data

Answer 7

“symptoms”
interview and health history
may be documented using quotes

Question 8

nursing process: objective data

Answer 8

"signs"
physical exam
diagnostic and lab data
observation of pt.'s behavior
- verbal and non-verbal communication

Question 9

nursing process: the diagnostic process

Answer 9

analysis and interpretation
- data validation and clustering
- derived from assessment which includes subjective an objective data and risk factors
identification of pt. health problem
- based on defining characteristics [i.e. pain, ineffective breathing]
formulation of nursing diagnosis

Question 10

nursing process: developing SMART goals

Answer 10

should be Specific for the pt.
should be Measurable
- i.e. pain rating from 0-10
should be Attainable
should be Realistic
should be Timely
- i.e. present a specific time frame

Question 11

nursing process: discharge planning

Answer 11

thought of upon admission to the facility or institution

it is part of the nursing care plan

Question 12

nursing process: implementation

Answer 12

fourth step of thee nursing process
implements the interventions that have been agreed upon by the pt. and the nurse
implementation process:
- reassessing the pt.
– interventions may have to change depending on the pt.’s status and response to interventions
- organizing resources and care delivery
- anticipating and preventing complications
- communicating nursing interventions
implementation skills
- cognitive, interpersonal, and psycho-motor skills

Question 13

nursing process: evaluation

Answer 13

it is the final step of the nursing process
measures the pt.’s response to nursing actions and the pt.’s progress toward achieving the goals
it is an on-going process
it requires critical thinking
it requires evaluative thinking
- performing assessments throughout the whole period of care
interpretation and summation of findings occur
remember to document

Question 14

electronic health records: EHR

Answer 14

electronic record of pt. health information generated whenever a pt. accesses medical care in any health care delivery setting
integrated all pertinent pt. information into one record
enables research and quality of care
provides continuity and quality of care
- pt.’s will not always just go to one facility so this keeps the information for each pt. at the ready

Question 15

electronic heath records: purpose of records

Answer 15

communication between different health care professionals and professions
legal documentation to serve a proof that care was given and interventions were done
financial billing which aids the process of reimbursement from insurance companies
education used for research purposes to aid in individual learning and team learning
aids in the navigation of the nursing process
provides readily available information for research
auditing and monitoring which confirms care was given to the pt.

Question 16

electronic health record: methods of recording

Answer 16

narrative documentation
- written expressively by the nurse
problem-oriented medical records
- uses a database to document assessment findings
- has a problem list, plan-of-care, and progress notes
source records
charting by exception
- only charting if there is a deviation from the norm
- charting anything that isn’t within normal limits
cases management and critical pathways

Question 17

electronic health record: legal responsibilities in documentation

Answer 17

standards of documentation are set by federal and state regulations, state statutes, standards of care and accrediting agencies
in the eyes of the law, “if you didn’t document it, you didn’t do it”

Question 18

electronic health record: maintaining pt. confiddentiality

Answer 18

it is the legal and ethical obligation of health care professionals to maintain pt. confidentiality
only staff who have direct involvement in a specific pt.’s care have legitimates access to records
health insurance portability and accountability act [HIPAA] governs all areas of pt. information and the management of their care

Question 19

electronic health record: guidelines for effective documentation

Answer 19

factual
- describes what is going on, what is the objective, decreases judgment, avoids vague statements [i.e. the pt. seems upset], avoids subjective terms [i.e. the wound is healing “nicely”]
accurate
- requires information to be given verbatim, using appropriate and accepted abbreviations
complete
- requires relevant and specific information, as possible
current
organized
- performed by the nurse/health care professional that gave care and should not be done under the name of someone else and vice versa

Question 20

electronic health record: change-of-shift report

Answer 20

“hand-off report”
provides continuity, individualized care
SBAR is a format type to giving half-off
- i.e. Situation [J.R. in 207b came in for___]’ Background [had a productive]; Assessment [specific assessment done by the health members from facility]; Recommendations
normal findings and routine information does not need to be provided
changes to health status, medications delivered, lab results, etc. do need to be reported

Question 21

electronic health records: telephone reports

Answer 21

read-backs are required if critical values are being reported
- this is a useful method to minimize errors

Question 22

electronic health records: telephone or verbal orders

Answer 22

frequently cause medical errors
no verbal orders unless it is an emergency situation
document that the order is a verbal order
student nurses can never take a verbal order

Question 23

electronic health records: transfer reports

Answer 23

pt. is going from one facility to another
medication reconciliation- accurate list of all pt. medications from admission through to discharge. with each transfer within the institution the list of medications must be reconciled for accuracy unless proper contraindication is given.

Question 24

electronic health records: incident reports

Answer 24

important part of quality improvement
always contact HCP when an incident occurs
do not mention in pt.’s medical record because it may be used against the health care professional in court
document objective description of incident, follow-up actions
goal is to identify changes needed to prevent future occurrence
- goal is not to place blame or to save oneself from legal ramifications… although, it does help
- goal is to find error in current practice, prevent any errors from reoccurring in the future
analysis helps identify trends, changes in policy and procedure, staff education programs

Question 25

medications: pharmokinetics

Answer 25

how medications affect the pt. the study of how medications: - enter the body [absorption] and all the processes that occur in the body - reach their site of action [distribution] - metabolism - metabolize and absorbed and distributed into cells, tissues, or organs - alter physiological functions - exit the body [excretion]

Question 26

medications: therapeutic effect

Answer 26

expected or predictable physiological response | i.e. administration of analgesic for pain relief

Question 27

medications:side effect

Answer 27

intended, secondary effect | i.e. benadryl works as an anti-histamine with a side effect of drowsiness

Question 28

medications: adverse effect

Answer 28

a severe response to a medication that is unintended, in which case administration should be stopped i.e. medications which causes severe nausea and vomiting

Question 29

medications: toxic effect

Answer 29

accumulation of medication in the bloodstream occurs either because the medication has been taken for a long time or its not being metabolized or excreted

Question 30

medications: idiosyncratic reaaction

Answer 30

over- or under-reaction to a medication | i.e. benadryl has a side effect of drowsiness, an idiosyncratic reaction is increased energy

Question 31

medications: allergic reaction

Answer 31

unpredictable response to a medication due to antibodies reacting against the medication may cause a mild or severe allergic reaction

Question 32

medications: serum half-life

Answer 32

time for medication concentration to be halved, form time the medication is absorbed this is important because at this point the effect of the medication decreases but we want to maintain the level of medication in the blood stream constant

Question 33

medications: onset

Answer 33

time it takes for a medication to produce a response | i.e. PO pain med.'s begin after 30 minutes

Question 34

medications: peak

Answer 34

time at which a medication reaches its highest effective concentration

Question 35

medications: trough

Answer 35

minimum blood serum concentration before next scheduled dose

Question 36

medications: duration

Answer 36

time medication take to produce greatest result

Question 37

medications: plateau

Answer 37

blood serum concentration is reached and maintained

Question 38

medications: role of the prescriber

Answer 38

can be the physician, nurse practitioner, or physician's assistant prescribers must document the reasoning, diagnosis, condition, and need for each medications order can be electronic, written, verbal, or through the telephone

Question 39

medications: implementing nursing actions to prevent medication errors

Answer 39

be informed of medication name, purpose, action, and potential undesired effects investigate further on refusal of medications have qualified nurses or physicians assess a medication history be properly advised of the experimental nature of medication receive labeled medications safely without discomfort [same discomfort may occur] receive appropriate supportive therapy not receive unnecessary medications informed of whether medications are part of research

Question 40

medications: synergistic effect

Answer 40

occurs when the combined effect of two medications is greater than the effect of the medication given separately these effect may be wanted

Question 41

medications: six rights of medication administration

Answer 41

``` right medication right patient right dose right route right time right documentation ```

Question 42

medications: three checks of medication administration

Answer 42

before checking the medication out of the cart when the medication is taken out of the cart upon getting to the pt.'s room

Question 43

medications: administering oral med.'s

Answer 43

easiest orute and most desirable allow time between medication administration and nutrition intake as the effects of the med. may diminish or alter assess whether the pt. is at risk for aspiration, if so, consider enteral tube administration of the medication

Question 44

medications: administering topical med.'s

Answer 44

always don glove to decrease the chance of absorption of the medication for transdermal patches, switch locations of placement

Question 45

medications: administering nasal med.'s

Answer 45

allow pt. to administer medication to themselves to encourage independence

Question 46

medications: administering eye med.'s

Answer 46

administer along the lower lid and sclera, toward the inner canthus

Question 47

medications: administering ear med.'s

Answer 47

pull pinna up and back to straighten the ear canal facilitating administration

Question 48

medications: administering vaginal med.'s

Answer 48

allow pt. to self-administer to encourage independence and allow for privacy

Question 49

medications: administering rectal med.'s

Answer 49

have pt. assume Sim's position making sure the tip of the suppository is lubricated

Question 50

medications: parenteral administration

Answer 50

procedure is to be performed using aseptic technique consider the volume of medication being administered, its characteristics and viscosity, and the location of injection sites

Question 51

nutrition: types of diets

Answer 51

NPO - nothing by mouth - indicated for pt.'s being prepped for surgery or a procedure - indicated for pt.'s with dysphagia clear liquids - indicated for pt.'s who have just undergone surgery or a procedure full liquids pureed - indicated for pt.'s with extreme tooth loss or lack of chewing abilities mechanical soft soft/low residue - indicated for pt.'s who are having GI complications high fiber - indicated for pt.'s who need improvement with their digestive system low sodium low cholesterol diabetic regular

Question 52

nutrition: aspiration prevention

Answer 52

keep pt. in a sitting position during feedings and an hour after feedings

Question 53

nutrition: care of pt. with enteral feeding

Answer 53

determine the length of tube needed for the particular pt. by measuring from the tip of the nose to the auricle and down to the xyphoid process confirm proper placement of the tube primarily by using x-ray

Question 54

nutrition: parenteral therapy

Answer 54

``` indications - pt. has a non-functioning GI system - pt. has a highly stressed system [i.e. burn victim] contents - essential nutrients route of administration - via a central line through the jugular vein or sub-clavian vein - via a PICC line [peripheral line] monitor lab values consistently use aseptic technique when giving TPN care complications: - hypo- or hyper-glycemia - electrolyte imbalance - misplacement of lumen - air in the lumen - occlusion in the lumen ```