Which of the following is correctly charted according to the six guidelines for quality
recording?
1. Was depressed today.
2. Respirations rapid; lung sounds clear.
3. Had a good day. Up and about in room.
4. Crying. States she doesn't want visitors to see her like this.
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, ANSWER IS D
- When recording subjective data, document the patient's exact words
within quotation marks whenever possible.
Airborne precautions
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MTV or My chicken hez tb measles, chickenpox (varicella) Herpes
zoster/shingles ,TB
N95 mask
PERRLA stands for
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pupils equal, round, reactive to light and accomodation
Ampules
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, •Ampules contain single doses of medication in a liquid.
•An ampule is made of glass with a constricted neck that must be snapped
off to allow access to the medication.
•A colored ring around the neck indicates where the ampule is prescored
so that you can break it easily.
•Use a disposable ampule breaker if available at facility (available in ACC
Lab Pack and should be used in lab)
•Make sure medicine is down in the bottle and not in the neck.
•Carefully aspirate the medication into a syringe (see Skill 31.4) with a filter
needle.
•Filter needles must be used when preparing medication from a glass
ampule to prevent glass particles from being drawn into the syringe.
•Do not use a filter needle to administer/inject a medication.
•Place an appropriate-size needle on the syringe after withdrawing the
medication from the ampule with the filter needle.
ANA Standards of Nursing Practice
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1. Assessment
2. Diagnosis
3. Outcomes Identification
4. Planning
5. Implementation
6. Evaluation
goals for immobility
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Focus on preventing problems or risks to impaired body alignment
Develop short term and long term goals
-Example → Hip Fracture Patient Goals:
, Patient will use walker to safely ambulate 25 feet in the hallway. Patient's
skin will remain intact. Patient will change position every 2 hours.
evalution: immobility
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Through the patient's eyes
Are the patient's expectations being met?
Patient outcomes
Make comparisons with baseline measures.
Consider standards for physical activity performance.
Compare actual outcomes with expected outcomes.
What does the presence of JVD indicate?
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Jugular vein distention is when the vein that runs down the right side of the
neck is swollen. This happens when blood is unable to flow as it should. The
blood backs up in the vein, increasing jugular vein pressure, or JVP. JVD is
usually a sign of heart failure, which often involves high blood pressure.
Other common symptoms may include: Shortness of breath, including fluid
on the lungs. Edema (swelling) in the feet, legs, and hands.
Vein should NOT be distended when pt. sits up. It should flatten out.
If an error is made while documenting in a paper chart, the nurse should:
1. Erase it or scratch it out
2. Leave a blank space in the note
recording?
1. Was depressed today.
2. Respirations rapid; lung sounds clear.
3. Had a good day. Up and about in room.
4. Crying. States she doesn't want visitors to see her like this.
Give this one a try later!
, ANSWER IS D
- When recording subjective data, document the patient's exact words
within quotation marks whenever possible.
Airborne precautions
Give this one a try later!
MTV or My chicken hez tb measles, chickenpox (varicella) Herpes
zoster/shingles ,TB
N95 mask
PERRLA stands for
Give this one a try later!
pupils equal, round, reactive to light and accomodation
Ampules
Give this one a try later!
, •Ampules contain single doses of medication in a liquid.
•An ampule is made of glass with a constricted neck that must be snapped
off to allow access to the medication.
•A colored ring around the neck indicates where the ampule is prescored
so that you can break it easily.
•Use a disposable ampule breaker if available at facility (available in ACC
Lab Pack and should be used in lab)
•Make sure medicine is down in the bottle and not in the neck.
•Carefully aspirate the medication into a syringe (see Skill 31.4) with a filter
needle.
•Filter needles must be used when preparing medication from a glass
ampule to prevent glass particles from being drawn into the syringe.
•Do not use a filter needle to administer/inject a medication.
•Place an appropriate-size needle on the syringe after withdrawing the
medication from the ampule with the filter needle.
ANA Standards of Nursing Practice
Give this one a try later!
1. Assessment
2. Diagnosis
3. Outcomes Identification
4. Planning
5. Implementation
6. Evaluation
goals for immobility
Give this one a try later!
Focus on preventing problems or risks to impaired body alignment
Develop short term and long term goals
-Example → Hip Fracture Patient Goals:
, Patient will use walker to safely ambulate 25 feet in the hallway. Patient's
skin will remain intact. Patient will change position every 2 hours.
evalution: immobility
Give this one a try later!
Through the patient's eyes
Are the patient's expectations being met?
Patient outcomes
Make comparisons with baseline measures.
Consider standards for physical activity performance.
Compare actual outcomes with expected outcomes.
What does the presence of JVD indicate?
Give this one a try later!
Jugular vein distention is when the vein that runs down the right side of the
neck is swollen. This happens when blood is unable to flow as it should. The
blood backs up in the vein, increasing jugular vein pressure, or JVP. JVD is
usually a sign of heart failure, which often involves high blood pressure.
Other common symptoms may include: Shortness of breath, including fluid
on the lungs. Edema (swelling) in the feet, legs, and hands.
Vein should NOT be distended when pt. sits up. It should flatten out.
If an error is made while documenting in a paper chart, the nurse should:
1. Erase it or scratch it out
2. Leave a blank space in the note
