PCC Exam 3

o2, urinary elim, bowel elim, pain mgt, skin/wound healing

What are the purposes of documentation?

communication, continuity, reimbursement, quality improvement, accreditation, research, educational tool

What are the purposes of chart review?

essential component of care, verify accuracy, id trends, develop conclusions, gather critical hx, baseline info, data, tx plan, orders

What are the elements of documentation?

factual (sub/objective), accurate and concise, complete and current (timely), organized

What are the components of nursing admission assessment?

baseline data to monitor change, DC planning info/needs

What are the components of admission database?

CC/reason for admission, physical assessment, vitals, allergies, current meds, ADL status, client support system and contact into

What are the aspects of care summary?

demographic data, med diagnoses, allergies, diet/activity orders, safety precautions, IV therapy orders, ordered tx, scheduled surgery, labs and tests, summary of meds, iso orders, DNR info

What are the aspects of MAR?

allergies and reactions, scheduled/routine meds, PRN meds, STAT meds, omitted meds

What are the 6 rights of med admin?

patient, drug, dose, route, time, documentation

What are the different types of oral medication?

pills (tablets, capsules, coated, meltaway), enteral (NG/G tube), syrups, liquids, elixirs, suspensions

What are the different types of topical medication?

lotions, creams, ointments, sprays, powder, patches (GLOVES REQUIRED)

What are the aspects of intradermal injections?

just below skin surface, small amount of med (usually 0.1mL), usually 1mL syringe, 26-28 gauge, 5-15 degree angle; in forearms, upper chest, upper back

What are the aspects of subcutaneous injections?

25-30 gauge needle, 3/8-1in, max amount 1mL, 45-90 degree; in back of upper arm, upper back, lower back, abdomen, top of thigh

What are the aspects of intramuscular injections?

21-23 gauge, 1-1.5 in, 90 degree angle, Z-track method; in delt, vastus lateralis, or ventral gluteal

A nurse is working on a busy medical-surgical unit using an electronic health record with pre-populated assessment fields. During the shift, the nurse completes routine assessments by selecting “within normal limits” for cardiovascular, respiratory, and neurological systems. The nurse documents “no changes noted” at the end of the shift and only adds free-text documentation when the patient reports new onset chest discomfort at 1430, which is then fully charted.

Which documentation system is being used, and what is the most significant documentation risk?

Charting by Exception (CBE); risk that subtle but clinically significant baseline deviations may be missed or assumed normal due to reliance on predefined standards.

A nurse is teaching a patient who is newly prescribed multiple medications for hypertension and diabetes. Which statement by the patient indicates a need for further teaching?

“If I feel better, I can stop taking my antibiotic early and save the rest for later.”

A nurse is preparing to administer oral medications. The nurse enters the room and sees the patient sitting in a chair. The nurse states, “Are you Mr. Wilson?” The patient nods yes. The nurse scans the medication and prepares to administer it.

Which action should the nurse take first?

Ask the patient to state their full name and date of birth.

Match the term with the appropriate description: Plan of Care

Includes provider prescriptions and the nursing care plan addressing identified patient problems.

Match the term with the appropriate description: Problem List

Concise list of actual and resolved patient problems derived from assessment data.

Match the term with the appropriate description: Database

A structured listing of demographic, medical history, nursing assessment, and psychosocial data that is updated as the patient’s condition changes.

Match the term with the appropriate description: Progress Notes

Interdisciplinary documentation organized by problem number that reflects patient progress over time.

A nurse is preparing to give a change-of-shift handoff report on a medical-surgical unit. Which action best demonstrates effective use of bedside handoff reporting while maintaining patient safety and confidentiality?

The nurse performs bedside handoff, introduces the oncoming nurse to the patient, reviews recent changes and plan of care at the bedside, and invites the patient to ask questions while ensuring privacy is maintained.