NU 136 FUNDAMENTALS LATEST
FINAL EXAM
Nursing practice regarding implementation and evaluation, you must
always_______________________________. - ANSWERS-follow
hospital procedure or policy
source-oriented charting - ANSWERS--Charting that is organized by the
"source" or author of the documentation (narrative)
-gives patient's condition and care in chronological order
problem-oriented medical record (POMR) - ANSWERS--documentation
system organized according to the person's specific health problems
-uses SOAP
What does SOAP mean? - ANSWERS-S: subjective
O: objective
A: assessment
P: plan
Focus charting - ANSWERS--Charting methodology for structuring
progress notes according to the focus of the note (e.g., symptoms and
nursing diagnosis).
END OF
PAGE
1
, NU 136 FUNDAMENTALS LATEST
FINAL EXAM
-Each note includes data, actions, and patient response (DAR or DAE)
What does DAR stand for? - ANSWERS-D-data
A-action
R-response
What does DAE stand for? - ANSWERS-D-data
A-action
E-evaluation
Tips for computer documentation - ANSWERS--refresh the computer
screen often to keep track of the most current medical orders and other
health care providers' entries
-document in a timely manner
-do not share passwords or computer codes
-review your notes for accuracy before you select "confirm" or "save"
-never walk away from your terminal without logging off
END OF
PAGE
2
, NU 136 FUNDAMENTALS LATEST
FINAL EXAM
Communication: general leads - ANSWERS--use general leads to get
the interaction on the way
-cannot be answered with "yes" or "no" and require a few more words
ex: "I feel guilty breaking my leg" and a general lead would be, "Tell me
more about that"
Communication: encouraging elaboration - ANSWERS-used when more
information is needed about a topic
ex: "Tell me more" or "I'm not certain that I follow what you mean"
end-of-shift report - ANSWERS--nurse to nurse
-walking rounds
-give only essential information
-1-3 min long
-allow time to ask and respond to questions
what position is used for pelvic exams? - ANSWERS-lithotomy position
END OF
PAGE
3
, NU 136 FUNDAMENTALS LATEST
FINAL EXAM
knee-chest position - ANSWERS--patient is lying face down with the
hips bent so that the knees and chest rest on the table
-used for rectal examination
how can lifestyle affect wound healing? - ANSWERS--a person who
does not smoke and who exercises regularly typically heals more
quickly
-Regular exercise enhances blood circulation and thus promotes healing
because blood brings oxygen and nutrients to the wound.
-Smoking reduces the functional hemoglobin of the blood, whick limits
oxygen-carrying capacity.
Medications that interfere wound healing - ANSWERS--steroids
(predizone)
-anti-inflammatory drugs (advil)
-anticoagulants (heparin: blood thinner)
How long are heat applications left in place? - ANSWERS-15-30
minutes
END OF
PAGE
4
FINAL EXAM
Nursing practice regarding implementation and evaluation, you must
always_______________________________. - ANSWERS-follow
hospital procedure or policy
source-oriented charting - ANSWERS--Charting that is organized by the
"source" or author of the documentation (narrative)
-gives patient's condition and care in chronological order
problem-oriented medical record (POMR) - ANSWERS--documentation
system organized according to the person's specific health problems
-uses SOAP
What does SOAP mean? - ANSWERS-S: subjective
O: objective
A: assessment
P: plan
Focus charting - ANSWERS--Charting methodology for structuring
progress notes according to the focus of the note (e.g., symptoms and
nursing diagnosis).
END OF
PAGE
1
, NU 136 FUNDAMENTALS LATEST
FINAL EXAM
-Each note includes data, actions, and patient response (DAR or DAE)
What does DAR stand for? - ANSWERS-D-data
A-action
R-response
What does DAE stand for? - ANSWERS-D-data
A-action
E-evaluation
Tips for computer documentation - ANSWERS--refresh the computer
screen often to keep track of the most current medical orders and other
health care providers' entries
-document in a timely manner
-do not share passwords or computer codes
-review your notes for accuracy before you select "confirm" or "save"
-never walk away from your terminal without logging off
END OF
PAGE
2
, NU 136 FUNDAMENTALS LATEST
FINAL EXAM
Communication: general leads - ANSWERS--use general leads to get
the interaction on the way
-cannot be answered with "yes" or "no" and require a few more words
ex: "I feel guilty breaking my leg" and a general lead would be, "Tell me
more about that"
Communication: encouraging elaboration - ANSWERS-used when more
information is needed about a topic
ex: "Tell me more" or "I'm not certain that I follow what you mean"
end-of-shift report - ANSWERS--nurse to nurse
-walking rounds
-give only essential information
-1-3 min long
-allow time to ask and respond to questions
what position is used for pelvic exams? - ANSWERS-lithotomy position
END OF
PAGE
3
, NU 136 FUNDAMENTALS LATEST
FINAL EXAM
knee-chest position - ANSWERS--patient is lying face down with the
hips bent so that the knees and chest rest on the table
-used for rectal examination
how can lifestyle affect wound healing? - ANSWERS--a person who
does not smoke and who exercises regularly typically heals more
quickly
-Regular exercise enhances blood circulation and thus promotes healing
because blood brings oxygen and nutrients to the wound.
-Smoking reduces the functional hemoglobin of the blood, whick limits
oxygen-carrying capacity.
Medications that interfere wound healing - ANSWERS--steroids
(predizone)
-anti-inflammatory drugs (advil)
-anticoagulants (heparin: blood thinner)
How long are heat applications left in place? - ANSWERS-15-30
minutes
END OF
PAGE
4
