PCR ATD Review #2 Answer Key PDF
Document Details
Uploaded by OptimisticAzalea6206
University of the Fraser Valley
Tags
Summary
This document is a review of patient care procedures, medical records, and nursing protocols. It covers topics like medication administration, vital signs, patient allergies, communication sheets, and discharge summaries. The document is a past exam paper for a nursing unit clerk program.
Full Transcript
## REVIEW II (NC03) PATIENT CHART RECORDS, ADMISSION TRANSFERS AND DISCHARGES ### NURSING UNIT CLERK PROGRAM 1. Patient who are hospitalized for medical treatment would be admitted to a **MEDICAL** nursing unit. 2. The **Medication Profile** is a quick reference of **DRUGS PATIENT IS ON**, **DRUGS...
## REVIEW II (NC03) PATIENT CHART RECORDS, ADMISSION TRANSFERS AND DISCHARGES ### NURSING UNIT CLERK PROGRAM 1. Patient who are hospitalized for medical treatment would be admitted to a **MEDICAL** nursing unit. 2. The **Medication Profile** is a quick reference of **DRUGS PATIENT IS ON**, **DRUGS THAT ARE D/ed.** and **DRUGS ON HOLD**. 3. Which form is used to record all orders given by the physician or medical staff? - **ORDERS** - **DIRECTIVES** - **PHYSICIAN'S ORDER SHEET (POS)** 4. The **Medication Administration Record (MAR)** is a personalized document for each patient, used to keep - **TO GIVE** - **DOSE** - **TIME** - **ROUTE** to give the medication. 5. The purpose of the **Vital Sign Record** is to record graphic representation of the patient's vital signs which include: - **TEMPERATURE** - **PULSE** - **RESPIRATIONS or RESPIRATION RATE** - **BLOOD PRESSURE** 6. When adding a Physicians order form to the patients chart the Unit Clerk must remember to - **PATIENT LABEL, or FORMIMPRINT** - **ALLERGIES** 7. The patient's **Kardex** is kept at the nursing unit in a: **KARDEX HOLDER** 8. The **DISCHARGE SUMMARY** is completed by the physician when the patient is discharged from the hospital. It is a brief summary of the patients care and history while in the hospital. 9. Information found on the Kardex may include; - **ACTIVITY** - **IN'S** - **LAB TEST** - **CARE PLANS** - **DIAGNOSTIC TEST** - **DIET** - **TREATMENTS** - **DEGREE OF INTERVENTION (MOST)** 10. The first form completed to start the patients chart is the **ADMISSION Record**. 11. Which form is completed by the nursing staff stating the patient's allergies? **ALLERGY/ADVERSE REACTION RECORD** 12. Who is responsible for completing the **Discharge Summary** once the patient is discharged? **PHYSICIAN** 13. The purpose of the **Communication Sheet** is for **COMMUNICATE** non-urgent information to the doctor. 14. What information can be found on the **Admission Record**? - **NAME** - **PHYSICIAN (S)** - **NEXT OF KIN (NOK)** - **ADMISSION DATE** - **DIAGNOSIS** - **ADDRESS** - **PHN** 15. What form is completed by the nursing staff giving the patient's discharge instructions? **DISCHARGE INSTRUCTIONS** 16. Staff are required to state this information on the **Signature Identification Record**: - **INITIALS** - **PRINTED NAME** - **SIGNATURE, DESIGNATION** 17. The purpose of the **MAR** is: - **TO KEEP A RECORD OF MEDICATIONS** - **TO GIVE, THE DOSE, TIME, "ROUTE"** 18. A method of alerting staff when two or more patients with the same last name are located on the same nursing unit is referred to as **NAME ALERT** 19. A patient who has been admitted to a health care facility at least overnight for care and treatment; **IN PATIENT** 20. The purpose of this form, completed by the nurse, is to give the nursing and medical staff a brief overall past and present history of the patient upon admission; **NURSING ADMISSION HISTORY** 21. When transcribing physician's orders onto the Kardex, is pen or pencil used and why? **PENCIL, EASIER TO UPDATE / MAKE CHANGES** 23. State 14 forms that are assembled in an admission chart pack by the Unit Clerk: - **MOST** - **PROGRESS NOTES** - **ALLERGY RECORD** - **SIGNATURE RECORD** - **COMMUNICATION** - **NURSING ADMISSION HISTORY** - **DIC SUMMARY** - **NURSING FLOWSHEET** - **DIC INSTRUCTIONS** - **MAR** - **MEDICATION PROFILE** - **KARDEX** - **ORDERS & DIRECTIVES** - **VITAL SIGN RECORD** 24. State the full term for the following abbreviations: 1. **UC** - **UNIT CLERK** 2. **HX** - **HISTORY** 3. **NAS** - **NO ADDED SALT** 4. **T** - **TEMPERATURE** 5. **BP** - **BLOOD PRESSURE** 6. **R** - **RESPIRATION/RECTAL/RIGHT** 7. **LPN** - **LICENSED PRACTICAL NURSE** 8. **CXR** - **CHEST X-RAY** 9. **DOB** - **DATE OF BIRTH** 10. **IV** - **INTRA VENOUS** 11. **OR** - **OPERATING ROOM** 12. **BRP** - **BATHROOM PRIVILEGES** 13. **s** - **WITHOUT** 14. **HS** - **HOURS OF SLEEP OR AT BEDTIME** 15. **DAT** - **DIET AS TOLERATED** 16. **PO** - **BY MOUTH (PER ORA), PHONE ORDERS, POST-OPERATIVE, PHYSICIAN ORDER** 17. **NKA** - **NO KNOWN ALLERGIES** 18. **PARR** - **POST ANAESTHETIC RECOVERY ROOM** 19. **DOD** - **DOCTOR OF THE DAY** 20. **ADM** - **ADMISSION** 21. **PAC** - **PRE-ADMISSION CLINIC** 22. **PAR** - **POST ANAESTHETIC ROOM** 23. **Paeds/Peds** - **PEDIATRICS** 24. **DI** - **DIAGNOSTIC IMAGING** 25. **ICU** - **INTENSIVE CARE UNIT** 26. **CCU** - **CARDIAC/CORONARY CARE UNIT** 27. **LPN** - **LICENSED PRACTICAL NURSE** 28. **RN** - **REGISTERED NURSE** 29. **Med** - **MEDICAL** 30. **Surg** - **SURGICAL** 31. **Obst** - **OBSTETRICAL** 32. **Mat** - **MATERNITY** 33. **Gyn** - **GYNECOLOGY** 34. **RR** - **RESPIRATORY RATE** 35. **02** - **OXYGEN** 36. **RAZ** - **RAPID ASSESSMENT ZONE** 37. **GM** - **GRAM** 38. **MRP** - **MOST RESPONSIBLE PHYSICIAN**
