HUC final exam
what is the difference between an invasive and a non invasive procedure -
✔️✔️invasive - a diagnostic/therapeutic technique that requires an incision or entry of a
body cavity or organ, requires a signed consent form
non invasive - a diagnostic/therapeutic technique that does not require that the skin be
broken or a cavity or organ of the body to be entered, doesn't require patient to sign a
consent form
list 3 things to include when ordering oxygen - ✔️✔️1- amount of oxygen
2- flow rate and concentration
3- type of delivery device (nasal prongs, mask)
list in order the 10 rules for transcribing doctors orders - ✔️✔️1- read the complete set
of doctors orders
2- order medications from the pharmacy department
3- complete all stat orders
4- place telephone calls as necessary
5- select the patients identifying information and collect all necessary forms
6- order diagnostic tests, treatment and supplies
7- kardex all the doctors orders except medication orders
8- complete medication orders by writing them on the MAR
9- recheck each step for accuracy and thoroughness
10- sign off the completed set of the doctors orders
list and define two different types of dialysis - ✔️✔️hemodialysis- the removal of waste
products from the blood through use of a machine through which the blood flows
peritoneal dialysis- filling the abdominal cavity with dialysis filtrate and allowing osmosis
to filter the blood over 4-8 hours
explain in detail the process of chart thinning - ✔️✔️1- remove older nurses notes,
medication forms, and other forms that are no longer needed
2- place the removed forms in an envelope
3- place the patients ID label on the outside of the envelope
4- write "thinned chart" and record the date with your first initial and last name on the
outside of the envelope
5-place a label on the front of the patients chart stating that the chart was thinned, along
with the date and the first initial and last name of the person thinning the chart
6- if the patient is transferred to another unit, transfer the thinned out forms with the
patients chart
, 7- when the patients is discharged, send all thinned out forms with the patients paper
chard to the health information management department
name 5 guidelines for writing on a patients chart - ✔️✔️- all entries must be made in ink
- the written entries must be legible and accurate
- recorded entries on the chart may not be obliterated or erased
-all entries must include the date and time the entry is made
-only approved abbreviations may be used
name 5 components of a medication order - ✔️✔️1- name
2- dose
3- route
4- frequency
5- qualifying phrase
define crackles - ✔️✔️a common, abnormal respiratory sound that consist of
discontinuous bubbling noises caused by fluid in the small airways and heard on
auscultation of the chest during inspiration
define stidor - ✔️✔️a high pitched harsh sound heard during inspiration that is caused
by obstruction of the upper airway sign of respiratory distress - requires immediate
attention
define CABG - ✔️✔️coronary artery bypass graft
define standing orders - ✔️✔️a doctors order that remains in effect and is executed as
ordered until the doctor discontinues or changes it
define one time orders - ✔️✔️a doctors order that is executed according to the
qualifying phrase, and then is automatically discontinued
define traction - ✔️✔️a mechanical pull to part of the body to maintain alignment and
facilitate healing, may be continuous or intermittent
describe the steps you would take when transcribing a doctors order and you find
several mistakes, ex: spelling errors, missing dose, missing signatures - ✔️✔️- call dr
to confirm spelling if required so you don't transcribe the wrong medication, dose etc
- call dr if there is a missing dose or route
- call dr if writing isn't legible
- get the appropriate resident or drs signature if missing, can't transcribe before orders
are signed off
what is the green sleeve for a patient that is being transferred to a hospice? what is in it
and why do we use it - ✔️✔️It is a plastic pocket that holds advanced care planning
what is the difference between an invasive and a non invasive procedure -
✔️✔️invasive - a diagnostic/therapeutic technique that requires an incision or entry of a
body cavity or organ, requires a signed consent form
non invasive - a diagnostic/therapeutic technique that does not require that the skin be
broken or a cavity or organ of the body to be entered, doesn't require patient to sign a
consent form
list 3 things to include when ordering oxygen - ✔️✔️1- amount of oxygen
2- flow rate and concentration
3- type of delivery device (nasal prongs, mask)
list in order the 10 rules for transcribing doctors orders - ✔️✔️1- read the complete set
of doctors orders
2- order medications from the pharmacy department
3- complete all stat orders
4- place telephone calls as necessary
5- select the patients identifying information and collect all necessary forms
6- order diagnostic tests, treatment and supplies
7- kardex all the doctors orders except medication orders
8- complete medication orders by writing them on the MAR
9- recheck each step for accuracy and thoroughness
10- sign off the completed set of the doctors orders
list and define two different types of dialysis - ✔️✔️hemodialysis- the removal of waste
products from the blood through use of a machine through which the blood flows
peritoneal dialysis- filling the abdominal cavity with dialysis filtrate and allowing osmosis
to filter the blood over 4-8 hours
explain in detail the process of chart thinning - ✔️✔️1- remove older nurses notes,
medication forms, and other forms that are no longer needed
2- place the removed forms in an envelope
3- place the patients ID label on the outside of the envelope
4- write "thinned chart" and record the date with your first initial and last name on the
outside of the envelope
5-place a label on the front of the patients chart stating that the chart was thinned, along
with the date and the first initial and last name of the person thinning the chart
6- if the patient is transferred to another unit, transfer the thinned out forms with the
patients chart
, 7- when the patients is discharged, send all thinned out forms with the patients paper
chard to the health information management department
name 5 guidelines for writing on a patients chart - ✔️✔️- all entries must be made in ink
- the written entries must be legible and accurate
- recorded entries on the chart may not be obliterated or erased
-all entries must include the date and time the entry is made
-only approved abbreviations may be used
name 5 components of a medication order - ✔️✔️1- name
2- dose
3- route
4- frequency
5- qualifying phrase
define crackles - ✔️✔️a common, abnormal respiratory sound that consist of
discontinuous bubbling noises caused by fluid in the small airways and heard on
auscultation of the chest during inspiration
define stidor - ✔️✔️a high pitched harsh sound heard during inspiration that is caused
by obstruction of the upper airway sign of respiratory distress - requires immediate
attention
define CABG - ✔️✔️coronary artery bypass graft
define standing orders - ✔️✔️a doctors order that remains in effect and is executed as
ordered until the doctor discontinues or changes it
define one time orders - ✔️✔️a doctors order that is executed according to the
qualifying phrase, and then is automatically discontinued
define traction - ✔️✔️a mechanical pull to part of the body to maintain alignment and
facilitate healing, may be continuous or intermittent
describe the steps you would take when transcribing a doctors order and you find
several mistakes, ex: spelling errors, missing dose, missing signatures - ✔️✔️- call dr
to confirm spelling if required so you don't transcribe the wrong medication, dose etc
- call dr if there is a missing dose or route
- call dr if writing isn't legible
- get the appropriate resident or drs signature if missing, can't transcribe before orders
are signed off
what is the green sleeve for a patient that is being transferred to a hospice? what is in it
and why do we use it - ✔️✔️It is a plastic pocket that holds advanced care planning
