©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
FPCC Exam 2 Study Guide Solutions
Documentation - ANSWER✔✔-act of recording patient status & care in written form or electronic form ,
or in a combination of the 2.
Explain the purposes of documentation - ANSWER✔✔-1. communication "continuity of care"
2. legally
3. financially
4. education & quality improvement
Explain how, when, & why to complete an incident report. - ANSWER✔✔--if an event that happens that
isn't consistent with routine care (a never event- pt developing a pressure ulcer, falling)
-*first assess the pt & the pt's response (vitals, comments, complaints of pain)*
-then inform provider
-provide objective descriptions & subjective comments
-dont include in the chart that you filed an incident report, only write what happened
-if it was a near miss, fill out an incident report to prevent it from happening in the future.
Page 1/82
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
Discuss the key elements of giving an oral patient report - ANSWER✔✔-face-to-face: ideal & most
common. keep organized by using SBAR
walking rounds- standard that the handoff should be given at the bedside
taped recording
must include significant info: name, age, diagnosis admitted with
changes in the treatment plan that happened
DO NOT include routine care
What abbreviations can be used in charting? - ANSWER✔✔-NONE. never accept an order that has an
abbreviation.
Explain the process for verifying or questioning a medical order. - ANSWER✔✔--If an order is written
illegibly on a paper order sheet or is entered into the EHR missing components, contact the provider.
-If you still do not feel comfortable after contacting the provider, you may refuse to carry it out.
Page 2/82
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
-Inform the chain of command of your refusal.
Nursing admission data forms - ANSWER✔✔-used to establish a baseline to monitor change, provides
information about the clients support system, contains the critical information on why the client is there.
Flowsheets/graphic records - ANSWER✔✔-use to document assessments and care that are performed
frequently, on a reoccurring schedule, or as a part of unit routines. (Vital signs)
Integrated plan of care - ANSWER✔✔-combination of care plan & patient chart.
Summarize the process for receiving & documenting verbal & telephone orders - ANSWER✔✔--Carefully
identify client.
-Immediately record the order.
-Always repeat the order back & document that too
-Document that you did that/read the order back.
-Question if needed.
-Document TO for telephone order, VO for verbal order.
-If uncomfortable/in a high-risk situation, ask them to repeat order to another nurse.
-The order has to be signed by the person who gave it to you within 24 hours, electronically or on paper
chart.
Page 3/82
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
How much fluid should we encourage our patients to drink daily? - ANSWER✔✔-2200-2700 mL
How is intake of ice chips measured for a patient's I&O? - ANSWER✔✔-1 cup of ice =1/2 a cup of fluid
What are colloids? - ANSWER✔✔-larger protein molecules
ex: albumin
Albumin & prealbumin are big factors in predicting ____ - ANSWER✔✔-skin health
What are examples of crystalloids? - ANSWER✔✔-small proteins
-sodium, chloride, potassium
Monitoring daily weights - ANSWER✔✔--Measure weights first thing in the morning, same time
everyday.
-Use same scale
-Void before weighing
-Client needs to be wearing the same thing each time
-Can delegate this
-Client can do this at home, if they are gaining more than *2.2 pounds a day*, they need to call the
provider & check in about what's going on
Page 4/82
FIRST PUBLISH OCTOBER 2024
FPCC Exam 2 Study Guide Solutions
Documentation - ANSWER✔✔-act of recording patient status & care in written form or electronic form ,
or in a combination of the 2.
Explain the purposes of documentation - ANSWER✔✔-1. communication "continuity of care"
2. legally
3. financially
4. education & quality improvement
Explain how, when, & why to complete an incident report. - ANSWER✔✔--if an event that happens that
isn't consistent with routine care (a never event- pt developing a pressure ulcer, falling)
-*first assess the pt & the pt's response (vitals, comments, complaints of pain)*
-then inform provider
-provide objective descriptions & subjective comments
-dont include in the chart that you filed an incident report, only write what happened
-if it was a near miss, fill out an incident report to prevent it from happening in the future.
Page 1/82
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
Discuss the key elements of giving an oral patient report - ANSWER✔✔-face-to-face: ideal & most
common. keep organized by using SBAR
walking rounds- standard that the handoff should be given at the bedside
taped recording
must include significant info: name, age, diagnosis admitted with
changes in the treatment plan that happened
DO NOT include routine care
What abbreviations can be used in charting? - ANSWER✔✔-NONE. never accept an order that has an
abbreviation.
Explain the process for verifying or questioning a medical order. - ANSWER✔✔--If an order is written
illegibly on a paper order sheet or is entered into the EHR missing components, contact the provider.
-If you still do not feel comfortable after contacting the provider, you may refuse to carry it out.
Page 2/82
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
-Inform the chain of command of your refusal.
Nursing admission data forms - ANSWER✔✔-used to establish a baseline to monitor change, provides
information about the clients support system, contains the critical information on why the client is there.
Flowsheets/graphic records - ANSWER✔✔-use to document assessments and care that are performed
frequently, on a reoccurring schedule, or as a part of unit routines. (Vital signs)
Integrated plan of care - ANSWER✔✔-combination of care plan & patient chart.
Summarize the process for receiving & documenting verbal & telephone orders - ANSWER✔✔--Carefully
identify client.
-Immediately record the order.
-Always repeat the order back & document that too
-Document that you did that/read the order back.
-Question if needed.
-Document TO for telephone order, VO for verbal order.
-If uncomfortable/in a high-risk situation, ask them to repeat order to another nurse.
-The order has to be signed by the person who gave it to you within 24 hours, electronically or on paper
chart.
Page 3/82
, ©EMILLECT 2024/2025 ACADEMIC YEAR. ALL RIGHTS RESERVED
FIRST PUBLISH OCTOBER 2024
How much fluid should we encourage our patients to drink daily? - ANSWER✔✔-2200-2700 mL
How is intake of ice chips measured for a patient's I&O? - ANSWER✔✔-1 cup of ice =1/2 a cup of fluid
What are colloids? - ANSWER✔✔-larger protein molecules
ex: albumin
Albumin & prealbumin are big factors in predicting ____ - ANSWER✔✔-skin health
What are examples of crystalloids? - ANSWER✔✔-small proteins
-sodium, chloride, potassium
Monitoring daily weights - ANSWER✔✔--Measure weights first thing in the morning, same time
everyday.
-Use same scale
-Void before weighing
-Client needs to be wearing the same thing each time
-Can delegate this
-Client can do this at home, if they are gaining more than *2.2 pounds a day*, they need to call the
provider & check in about what's going on
Page 4/82
