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.
/.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.
-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.
/.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
-1 pound increase is about 500mLs of fluid retention.
/.We lose about how much fluid in our stool per day? - Answer-100-200 mL/day
,/.How much fluid do we lose through urine a day? - Answer-1500mL/day
/.What are examples of insensible losses & can they be measured? - Answer--lungs,
skin
cannot be measured
/.Intracellular fluid - Answer-contained within the cells.
accounts for 40% of body weight & is essential for cell function & metabolism
/.Extracellular fluid - Answer-outside the cells. carries water, electrolytes, nutrients, and
oxygen to the cells & removes waste.
accounts for 20% of body weight
/.interstitial fluid - Answer-lies in the spaces between the body cells
/.intravascular fluid - Answer-plasma within the blood. main function is to transport blood
cells
/.transcellular fluid - Answer-specialized fluids that are contained body spaces (ex:
cerebrospinal fluid)
/.Third spacing - Answer-fluid is trapped in a third compartment- not within interstitial or
the intravascular spaces.
/.Sodium is a major cation in the _____ fluid - Answer-extracellular
/.Normal Na+ level - Answer-135-145 mEq/L
/.Sodium function - Answer-1. regulates fluid volume
2. helps maintain blood volume
3. interacts with calcium to maintain muscle contraction.
4. stimulates conduction of nerve impulses.
/.Sodium regulation & sources - Answer--regulated by aldosterone & ADH
-reabsorbed & excreted through kidneys
-low sodium may be caused by excess water intake
sources: table salt, soy sauce, cured pork, cheese, milk, processed foods, canned
products, & foods preserved w/ salt
/.Potassium is major cation in the _____ fluid - Answer-intracellular
/.Normal K+ level - Answer-3.5-5.0 mEq/L
/.Potassium functions - Answer-1. maintains ICF osmolality
, 2. *regulates conduction of cardiac rhythm*
3. transmits electrical impulses
4. assists with acid base balance
/.Potassium regulation & sources - Answer--regulated by aldosterone
-excreted & conserved through kidneys
-lost through vomiting & diarrhea
-loss triggered by many diuretics
sources: bananas, oranges, apricots, figs, dates, carrots, potatoes, tomatoes, spinach,
dairy, & meats
/.What is the most abundant electrolyte in the body? - Answer-Calcium
/.Normal Ca++ level - Answer-9.0-10.5 mg/dL
/.Ca++ functions - Answer-1. promotes transmission of nerve impulses
2. major component of bone & teeth
3. regulates muscle contractions
4. maintains cardiac automaticity
5. essential in forming blood clots
6. catalyst for cellular activities
/.Ca++ regulation & sources - Answer-1. combines with phosphorus to form mineral
salts of bone & teeth
2. calcium & phosphorus have an *inverse* relationship
3. PTH stimulates release of calcium from bones & reabsorption from kidneys &
intestines
sources: milk, milk products, dark green leafy vegetables, salmon, calcium fortified
foods such as breads & cereals
/.What is the second most abundant cation in ICF? - Answer-Magnesium
/.Mg++ normal level - Answer-1.3-2.1 mEq/L
/.Mg++ functions - Answer-1. involved in protein & carb metabolism
2. necessary for protein & DNA synthesis within cell
3. maintains normal intracellular levels of potassium
4. involved in electrical activity in nerve & muscle membranes including the heart
/.Mg++ regulation & sources - Answer-1. ingested in diet & absorbed through large
intestines
2. excreted by kidneys
3. loss may be triggered by diuretics, poorly controlled diabetes, & *excess alcohol
intake*
