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Nursing Fundamentals: Vital Signs and Medication Administration
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Nursing Fundamentals: Vital Signs and Medication Administration

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Questions and Answers

What is the primary goal of a Clinical Decision Support System (CDSS)?

  • To improve nurse job satisfaction
  • To reduce hospital costs
  • To develop clinical databases
  • To generate tailored recommendations for individual patients (correct)
  • What is the main advantage of using a critical pathway design in a Nursing Clinical Information System (NCIS)?

  • Better documentation quality
  • Increased nurse job satisfaction
  • Reduced hospital costs
  • Interprofessional management of information (correct)
  • What is the primary focus of a nursing model design in a Nursing Clinical Information System (NCIS)?

  • Developing clinical databases
  • Reducing errors of omission
  • Improving nurse job satisfaction
  • Facilitating documentation of nursing process activities (correct)
  • What is the main function of the knowledge base within a Clinical Decision Support System (CDSS)?

    <p>To link information required for clinical decisions to generate tailored recommendations</p> Signup and view all the answers

    What is the primary focus of nursing informatics?

    <p>Integrating nursing science, computer science, and information science</p> Signup and view all the answers

    What is the main advantage of using a Nursing Clinical Information System (NCIS)?

    <p>Better information access and documentation quality</p> Signup and view all the answers

    What is the primary goal of informatics competencies for nursing graduates?

    <p>To be knowledgeable in the science and application of nursing informatics</p> Signup and view all the answers

    How many designs are typically used in a Nursing Clinical Information System (NCIS)?

    <p>Two</p> Signup and view all the answers

    What is the primary focus of the principle of beneficence in healthcare?

    <p>Acting in the best interest of the patient</p> Signup and view all the answers

    What is the term for the branch of ethics that focuses on healthcare?

    <p>Bioethics</p> Signup and view all the answers

    What is the primary goal of values clarification in ethical decision-making?

    <p>To distinguish between values, facts, and opinions</p> Signup and view all the answers

    What is the term for a deeply held personal belief about the worth of an idea, custom, or object?

    <p>Value</p> Signup and view all the answers

    What is the primary focus of the principle of autonomy in healthcare?

    <p>Freedom of external control</p> Signup and view all the answers

    What is the term for a set of guiding principles that all members of a profession accept?

    <p>Code of ethics</p> Signup and view all the answers

    What is the term for a situation where two opposing courses of action can both be justified by ethical principles?

    <p>Ethical dilemma</p> Signup and view all the answers

    What is the primary focus of the principle of nonmaleficence in healthcare?

    <p>Avoiding harm or hurt to patients</p> Signup and view all the answers

    What is the primary purpose of an acuity rating system?

    <p>To determine hours of care and number of staff required</p> Signup and view all the answers

    What is the basis of a patient's acuity level?

    <p>Type and number of nursing interventions required</p> Signup and view all the answers

    What is the range of a patient's acuity level classification?

    <p>1 to 5</p> Signup and view all the answers

    What governs documentation in the Long-Term Health Care Setting?

    <p>Individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS)</p> Signup and view all the answers

    What is the primary goal of health care information technology (HIT)?

    <p>To enhance quality and efficiency of care</p> Signup and view all the answers

    What are the two types of health care information systems?

    <p>Clinical and administrative</p> Signup and view all the answers

    What is an example of a clinical information system (CIS)?

    <p>Computerized provider order entry (CPOE)</p> Signup and view all the answers

    What is the function of computerized provider order entry (CPOE)?

    <p>To allow healthcare providers to directly enter standardized orders for patient care</p> Signup and view all the answers

    What is moral distress?

    <p>When taking a specific action while believing that action to be wrong</p> Signup and view all the answers

    What is the purpose of an ethics committee?

    <p>To address ethical issues and dilemmas</p> Signup and view all the answers

    What is the first step in processing an ethical problem?

    <p>Ask: Is this an ethical problem?</p> Signup and view all the answers

    What is the focus of deontology in ethics?

    <p>The act itself and its adherence to rules and principles</p> Signup and view all the answers

    What is the primary focus of utilitarianism?

    <p>The outcome of the action and the greatest good for the greatest number</p> Signup and view all the answers

    What is the focus of feminist ethics?

    <p>Natural caring for others and practical situations</p> Signup and view all the answers

    What is the focus of ethics of care?

    <p>Understanding relationships and personal narratives</p> Signup and view all the answers

    What is a common source of ethical problems in healthcare?

    <p>All of the above</p> Signup and view all the answers

    What is the main purpose of documenting patient assessment data?

    <p>To record patient physiological data and routine care</p> Signup and view all the answers

    What is the philosophy behind charting by exception?

    <p>That all standards for normal assessment findings are met unless otherwise documented</p> Signup and view all the answers

    What is the purpose of a discharge summary form?

    <p>To prepare patients for a safe and timely discharge</p> Signup and view all the answers

    How should the abbreviation 'unit' be written in nursing documentation?

    <p>unit</p> Signup and view all the answers

    What is the purpose of a care plan?

    <p>To identify and address a patient's specific health problems</p> Signup and view all the answers

    What is the main characteristic of a flow sheet in nursing documentation?

    <p>It is organized by body systems and navigated through the use of a computer mouse</p> Signup and view all the answers

    What should be included in a patient care summary?

    <p>All relevant information about the patient's care</p> Signup and view all the answers

    What is the purpose of progress notes in nursing documentation?

    <p>To monitor and record the progress made toward resolving a patient's problems</p> Signup and view all the answers

    Study Notes

    Standards and Guidelines for Quality Nursing Documentation

    • Record entries and reports should be organized, concise, clear, and complete, containing essential information.
    • Use standardized abbreviations, such as "unit" instead of "unit of measurement", and avoid using decimal points after whole numbers.

    Methods of Documentation

    • Documentation of patient assessment data includes:
      • Flow sheets, which are organized by body systems and navigated using a computer mouse.
      • Progress notes, which monitor and record patient progress toward resolving problems.
      • Charting by exception, which assumes that all standards for normal assessment findings or routine care activities are met unless otherwise documented.

    Common Record-Keeping Forms within the Electronic Health Record

    • Includes:
      • Admission nursing history form
      • Patient care summary
      • Care plans
      • Discharge summary forms

    Acuity Rating Systems

    • Used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours.
    • Patient acuity level is based on the type and number of nursing interventions required by the patient over a 24-hour period.

    Documentation in the Long-Term Health Care Setting

    • Governed by individual state regulations, The Joint Commission, and Centers for Medicare and Medicaid Services (CMS).
    • Notes: Check for pain management.

    Informatics and Information Management in Health Care

    • Health care information technology (HIT) enhances quality and efficiency of care by recording, monitoring, and delivering patient care.
    • Health care information system (HIS) consists of two types:
      • Clinical information system (CIS)
      • Administrative information system
    • Examples of CIS:
      • Computerized provider order entry (CPOE)
      • Nursing clinical information systems (NCIS)
    • NCIS designs:
        1. Nursing model
        1. Critical pathway
    • Advantages of NCIS:
      • Better information access
      • Better documentation quality
      • Reduced errors of omission
      • Reduced hospital costs
      • Increased nurse job satisfaction
      • Clinical database development

    Clinical Decision Support Systems (CDSS)

    • Aids and supports clinical decision making by providing tailored recommendations for individual patients.

    Nursing Informatics

    • Specialty area of practice that integrates nursing science, computer science, and information science.
    • Informatics competencies for nursing graduates require knowledge of nursing informatics science and application.

    Ethics and Values

    Basic Terms in Health Ethics

    • Morals: Judgment or behavior based on beliefs
    • Value: A deeply held personal belief about the worth of an idea, custom, object
    • Bioethics: Branch of ethics in healthcare
    • Autonomy: Freedom of external control
    • Beneficence: A positive action to help others
    • Nonmaleficence: Avoidance of harm or hurt
    • Justice: Fairness and distribution of resources
    • Fidelity: Faithfulness and keeping promises

    Professional Nursing Code of Ethics

    • Code of ethics: Set of guiding principles that all members of a profession accept
    • Key principles:
      • Advocacy
      • Responsibility
      • Accountability
      • Confidentiality

    Values

    • Value clarification: Resolving ethical conflicts by distinguishing among value, fact, and opinion
    • Clarifying values: Important for effective ethical discourse

    Nursing Point of View

    • Types of ethical problems:
      • Ethical dilemma
      • Moral distress
    • Ethics committees
    • Processing an ethical problem:
      • Step 1: Ask if it's an ethical problem
      • Step 2: Gather relevant information
      • Step 3: Identify ethical elements and examine values
      • Step 4: Name the problem
      • Step 5: Identify possible courses of action
      • Step 6: Create and implement an action plan
      • Step 7: Evaluate the action plan

    Issues in Health Care Ethics

    • Social media: Can be a supportive source of information about patient care or professional nursing activities
    • Quality of life: Deeply personal
    • Care at the end of life: Frequent source of ethical problems
    • Access to health care: Not always available

    Approaches to Ethics

    • Deontology: Defines actions as right or wrong based on adherence to rules and principles
    • Utilitarianism: Focuses on the greatest good for the greatest number of people
    • Casuistry: Case-based reasoning, focusing on the details of a situation
    • Feminist ethics: Natural caring for others is the basis for moral behavior, focusing on practical situations and relationships
    • Ethics of care: Focuses on understanding relationships, personal narratives, and context in which ethical problems arise.

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    Related Documents

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    Description

    This quiz covers the basics of nursing practice, including vital signs, pain assessment, and administration of medications and treatments. It also reviews proper recording and reporting techniques.

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