Ameritech Nur 112 Exam 3 Questions and Answers Already Passed
See box 16-1 page 342 - Answers What are the guidelines for documentation?
To help health care professionals from different disciplines (who interact with the patient at different
times) - Answers Primary purpose of patient record?
U write unit
IU write international unit
Q.D.,qd write daily
Q.O.D. qod write every other day
Trailing zero Write X mg
Lack of leading zero 0.Xmg
MSO and MGSO write morphine sulfate or magnesium sulfate - Answers Do not use
1.Record the orders in the patient's medical record
2. Read back the order to verify
3. Date and note the time of order
4. Record VO's (Verbal orders) name of physician followed by nurse own name and title - Answers How
would a RN receive a verbal order?
Paper format in which health care group keeps data on it's own separate form
ex: admission sheet
flow sheet (vitals)
medications
nurses notes
doctors notes
medical history - Answers Source orientated record
EHR Electronic health records
PHR Personal health records-pt updates information via computer. Easy way to keep up to date for self
care and communication with provider
,POMR problem oriented patient record-focus's on the patient's problems instead of around sources of
information.
PIE charting-The plan of care is incorporated into the progress notes. Use fill in the blank flow sheets -
Answers Different methods of documentation?
Pre-printed fill in the blank assessment forms. Patient problems are numbered following the PIE format
(problem, interventation, evaluation). Documentation tools examples: pulse, RR, BP, body temp..etc.. -
Answers What is a flowsheet?
Shorthand documentation, you only document the "abnormal findings" quick method - Answers
Charting by exception (CBE)
Summarizes the reason for treatment, significant findings, the procedures performed and treatment
rendered, patient's condition on discharge/transfer, any any specific information for family - Answers
Discharge summary
Identify/Introduction: communicate who you are, where you are, and why you're communicating
Situation: communicate what is occurring and why the patient is being handed off to another dept/unit
Background: explain what led up to the current situation and put in context if necessary
Assessment: give your impression of the problem
Recommendation: explain what you would do to correct the problem - Answers ISBAR
When a patient is being replaced by a different nurse for continuation of care. Can be written form,
orally in a meeting, audio/videotaped. Usually identifying patient
Current health status
Pertinent monitoring (lab, radiology...etc.)
Abnormal findings
Current orders
Upcoming orders
Any unfilled ordered
, Patient/family concerns - Answers What are common methods for change of shift reports?
Tool to document the occurence of anything out of the ordinary that results in potential harm to the
patient - Answers Incident report/variance report
Specialty that integrates nursing science, computer science, and information science to manage and
communicate data, information, and knowledge in nursing practice. - Answers Nursing informatics
Aware of knowledge level, physical health state, lifestyle...etc.. Can help prevent motor vehicle
accidents, falls, fire, safety awareness, violent behavior...The nurse should work with the patient/family
together to reduce accident risks - Answers Factors that affect safety in an individuals environment
Can occur at any age, but usually 65 years of age or older. Box 26-1 page 694
Keep stairways clear
Maintain walkways
Provide grab bars
Raised toilet seat
Eliminate scatter rugs - Answers Who is at the most risks for falls?
Children are the most at risk.
Products containing acetaminophen
House cleanings
Lead
Insecticides
Hydrocarbons - Answers Poisoning from common agents
Greater incidence in children, newborns highest risk when sleeping
Common causes:
Drowning age 1-4
Choking
Gas/smoke poisoning. - Answers What is suffocation & choking?
Physical abuse
Sexual abuse
See box 16-1 page 342 - Answers What are the guidelines for documentation?
To help health care professionals from different disciplines (who interact with the patient at different
times) - Answers Primary purpose of patient record?
U write unit
IU write international unit
Q.D.,qd write daily
Q.O.D. qod write every other day
Trailing zero Write X mg
Lack of leading zero 0.Xmg
MSO and MGSO write morphine sulfate or magnesium sulfate - Answers Do not use
1.Record the orders in the patient's medical record
2. Read back the order to verify
3. Date and note the time of order
4. Record VO's (Verbal orders) name of physician followed by nurse own name and title - Answers How
would a RN receive a verbal order?
Paper format in which health care group keeps data on it's own separate form
ex: admission sheet
flow sheet (vitals)
medications
nurses notes
doctors notes
medical history - Answers Source orientated record
EHR Electronic health records
PHR Personal health records-pt updates information via computer. Easy way to keep up to date for self
care and communication with provider
,POMR problem oriented patient record-focus's on the patient's problems instead of around sources of
information.
PIE charting-The plan of care is incorporated into the progress notes. Use fill in the blank flow sheets -
Answers Different methods of documentation?
Pre-printed fill in the blank assessment forms. Patient problems are numbered following the PIE format
(problem, interventation, evaluation). Documentation tools examples: pulse, RR, BP, body temp..etc.. -
Answers What is a flowsheet?
Shorthand documentation, you only document the "abnormal findings" quick method - Answers
Charting by exception (CBE)
Summarizes the reason for treatment, significant findings, the procedures performed and treatment
rendered, patient's condition on discharge/transfer, any any specific information for family - Answers
Discharge summary
Identify/Introduction: communicate who you are, where you are, and why you're communicating
Situation: communicate what is occurring and why the patient is being handed off to another dept/unit
Background: explain what led up to the current situation and put in context if necessary
Assessment: give your impression of the problem
Recommendation: explain what you would do to correct the problem - Answers ISBAR
When a patient is being replaced by a different nurse for continuation of care. Can be written form,
orally in a meeting, audio/videotaped. Usually identifying patient
Current health status
Pertinent monitoring (lab, radiology...etc.)
Abnormal findings
Current orders
Upcoming orders
Any unfilled ordered
, Patient/family concerns - Answers What are common methods for change of shift reports?
Tool to document the occurence of anything out of the ordinary that results in potential harm to the
patient - Answers Incident report/variance report
Specialty that integrates nursing science, computer science, and information science to manage and
communicate data, information, and knowledge in nursing practice. - Answers Nursing informatics
Aware of knowledge level, physical health state, lifestyle...etc.. Can help prevent motor vehicle
accidents, falls, fire, safety awareness, violent behavior...The nurse should work with the patient/family
together to reduce accident risks - Answers Factors that affect safety in an individuals environment
Can occur at any age, but usually 65 years of age or older. Box 26-1 page 694
Keep stairways clear
Maintain walkways
Provide grab bars
Raised toilet seat
Eliminate scatter rugs - Answers Who is at the most risks for falls?
Children are the most at risk.
Products containing acetaminophen
House cleanings
Lead
Insecticides
Hydrocarbons - Answers Poisoning from common agents
Greater incidence in children, newborns highest risk when sleeping
Common causes:
Drowning age 1-4
Choking
Gas/smoke poisoning. - Answers What is suffocation & choking?
Physical abuse
Sexual abuse
