Nur 155 Exam 1 (Galen) EXAM Questions and Verified Answers
, Who is able to access an EMR? (electronic medical record)
people with appropriate need for access with a login username and password
Why should medications be documented immediately after they are given?
To avoid confusion and double dosing.
If a mistake is made while paper documenting how should you proceed?
Draw a line through and write error above or after the entry along with the nurses initials
followed by the correct entry
SBAR
Situation
Background
Assessment
Recommendation
Orientation or introductory phase
• Making introductions, establishing professional role boundaries (formally or
informally) and expectations, and clarifying the role of the nurse
• Observing, interviewing, and assessing the patient, followed by validation of
perceptions
• Identifying the needs and resources of the patient