30 Questions
What is the primary purpose of admitting a patient for observational stay?
To monitor vital signs and detect any potential complications
What is the main difference between elective and emergency admissions?
The timing and preparation of the admission
What is the primary responsibility of the admitting department?
Entering and accepting patients into the healthcare facility
What is the purpose of an address or graph card in the admission process?
To identify the patient's address and contact information
What is the main reason for admitting a patient for a diagnostic investigation?
To determine the underlying cause of a patient's symptoms
What is the purpose of a consent form in the admission process?
To obtain patient consent for treatment
What is the primary purpose of a client's chart in healthcare?
To facilitate communication between different healthcare professionals
What is the main function of a nurse's admission assessment?
To provide a summary of nursing history and physical assessment
What is the purpose of a physician's order sheet?
To serve as a record of physician's orders for treatment and medications
What is the main function of a graphic sheet and flow sheet in a patient's chart?
To record repeated observations and measurements, such as vital signs and intake/output
What is the purpose of a discharge summary in a patient's chart?
To summarize the patient's condition, progress, and rehabilitation needs at time of discharge
What is the primary purpose of a TPR sheet in a patient's chart?
To show patient clinical information for physicians to judge patient condition
What is the primary goal of identifying a patient during the admission process?
To confirm the patient's identity
What type of medication order is given on an 'as needed' basis for specific signs and symptoms?
PRN Medication Orders
What is the term for the movement of a patient within the same healthcare facility?
Transfer
What is the purpose of the Seven Important Questions before administering medication?
To ensure the correct medication is administered
Which of the following is NOT a type of nursing responsibility during admission?
Provide medication
What is a concern for newly admitted patients?
Decreased privacy
What is the primary purpose of a Kardex form?
To provide a quick reference to a client's current orders
What is Kardexing?
The process of recording and updating doctor's orders on the Kardex form
What is the primary goal of accurate documentation in charting?
To provide a clear picture of the client's situation
What is the purpose of a Kardex file?
To organize and store Kardex forms for each patient in the nursing unit
What is included in the basic demographic data on a Kardex form?
Basic information such as name, room number, age, and admission date
What is the significance of matching the medication log entry and the order?
To prevent medication errors and ensure accuracy
What is the definition of pulse pressure?
The difference between the systolic and diastolic pressure
Which type of sphygmomanometer eliminates the need to listen to the sounds of the client's systolic and diastolic blood pressures through a stethoscope?
Electronic sphygmomanometer
What is the term for the act of bringing oxygen into the body and removing carbon dioxide?
Respiration
What is the term for the fluids that enter the client's body?
Intake
Which pulse site is located in the neck?
Carotid pulse
What is the device used to measure blood pressure?
Sphygmomanometer
Study Notes
Medication Administration
- Medication log entry, order, and prescription label must match
- Documentation is also known as record keeping
- Kardex is a form or card used to record doctor's orders and organize information for quick reference
Kardex
- Kardex form is used by nursing staff to record doctor's orders
- Kardex file is a portable file that contains and organizes kardex forms for each patient in the nursing unit
- Kardexing is the process of recording and updating doctor's orders on the kardex form
- Kardex contents include basic demographic data, list of medications, intravenous fluids, daily treatments, diagnostic procedures, allergies, and specific data
Charting
- Charting is the process of entering information in the patient's record
- Types of charting include narrative, observational, and outpatient stay
- General principles of charting include accuracy, with documented observations giving an appropriate picture of the client's situation
Admission
- Admission is the entry and acceptance of a patient to stay in a health facility for observation, investigation, and treatment
- Types of admissions include inpatient stay (longer than 24 hours) and outpatient stay (less than 24 hours)
- Inpatient stay can be elective/planned, routine, or emergency
- Responsibilities of the admitting department include preparing for admission, completing medical records, and obtaining consent forms
Client's Chart
- Client's chart is a formal, legal document that provides evidence of a client's care
- Purposes of a client's chart include communication, planning client care, and auditing health agencies
- Components of a client's chart include physician's order sheet, nurse's admission assessment, graphic sheet, medical history, and physician's progress notes
Vital Signs
- Pulse pressure is the difference between the diastolic and systolic pressure
- Pulse sites include temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, and pedal (dorsalis pedis)
- Respiration is the act of bringing oxygen into the body and removing carbon dioxide
- Blood pressure is the force of blood against the arterial walls in the body, measured using a sphygmomanometer
- Types of sphygmomanometers include aneroid, mercury, and electronic
- Intake refers to all fluids entering the client's body, while output refers to all fluids that leave the client's body
Test your knowledge of the client's chart, a formal document that records a patient's clinical data and medical history. Learn about the purposes of the client's chart, including communication and planning client care.
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