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Exam (elaborations)

Nur 150 Final Hondros Questions with correct answers

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Nur 150 Final Hondros Questions with correct answers

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Nur 150 Final Hondros Questions with
correct answers

Electronic Health Record

EHR is charting electronically. (Obviously) The point of it is being more efficient and accessible. Also
helps in transferring information from one place to another. Makes it easier to find information
about patients from other facilities. (Example: Drug seeking patients going from hospital to hospital
looking for a quick fix)

SOAPE Charting

- Subjective: What the patient states or feels.

- Objective: Information that the nurse can measure or facts.

- Assessment: Assessing the patient.

- Plan: Plan of care.

- Evaluation: Was this plan of care effective or not?

Subjective

What the patient states or feels.

Objective

Information that the nurse can measure or facts.

Assessment

Assessing the patient.

Plan

Plan of care.

Evaluation

Was this plan of care effective or not?

SOAPIER Charting

- Subjective: What the patient states or feels.

- Objective: Information the nurse can measure or facts.

- Assessment: Assessing the patient.

- Plan: Plan of care.

- Intervention: The care given, or action taken.

- Evaluation: Was this plan effective or not?

, - Revision: What are some changes that can be made?

Intervention

The care given, or action taken.

Evaluation

Was this plan effective or not?

Revision

What are some changes that can be made?

Focus Charting

- Data

- Action

- Response and evaluation

- Education and patient teaching

Protecting/Correcting Data

∙ It is the RN’s duty to do the patient’s initial admission nursing history, physical assessment, and
development of care plan.

∙ LPN’s role is to assist the RN during these plans.

∙ Do not erase, white out or scratch out information that was charted. This looks like you could be
hiding something. Instead draw a single line through the error and follow facility’s policy for
identifying errors.

∙ Chart only for yourself, do not chart for anyone else.

∙ Use only black ink if paper charting.

∙ Protect your computer passwords.

∙ Record only facts. Do not chart opinions.

Intramuscular Injections

- Needle into the muscle.

- Sites: Ventrogluteal (side of hip), Vastus lateralis muscle (middle of thigh),

Deltoid muscle (shoulder)

- This is most used for things like steroid shots, larger amount of medications,

thicker medications.

Intradermal Injections

- Needle into the dermis layer.

- Sites: Inner aspect of the lower arm, upper chest or the scapular area

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