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74 Cards in this Set
- Front
- Back
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The mission of the Board of Nurse Examiners for the State of Texas is what/
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Protect and promote the welfare of the people of Texas by ensuring each person holding a license as a nurse in the state of Texas is competent to practice safely.
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The Board fulfills its mission through what?
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regulation of the practice of nursing and the approval of nursing education programs.
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The mission, derived from where?
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Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or special interest group
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Purpose and Function of the BON is ?
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Interpret the NPA and the rules and regulations relating to nursing education, licensure, and practice to nurses, employers and the public to ensure informed personnel.
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Receive and investigate complaints.
¡ Discipline violators ¡ Provide mechanism for public comment ¡ Establishing criteria for licensing nurses |
Purpose and Function of the BON?
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Purpose and Function of the BON is ?
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Establish standards
Monitor the examination results to determine variances in educational effectiveness. ¡ Oversees procedures for nursing licensing examinations ¡ Issuing and transferring nursing licenses |
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Purpose and Function of the BON is ?
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Provide consultation and guidance to nurse education institutions and facilitate self-study, evaluation and development of effective nurse education programs.
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Purpose and Function of the BON is ?
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Provide advice and counsel to faculty of educational programs, to staff of health agencies utilizing nursing services, and to practitioners of nursing to continually improve professional service delivery
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Purpose and Function of the BON is ?
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Implement and manage all other programs.
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State Nurse Practice Acts
does what? |
Defines the scope of nursing practice
¡ Establishes the limits to that practice ¡ Identifies the titles that nurses must use, such as licensed practical nurse or registered nurse ¡ Authorizes a board of nursing to oversee nursing practice ¡ Determines what constitutes grounds for disciplinary action |
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Board of Nursing does what?
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Responsible for suspending and revoking licenses
¡ Reviews applications asking for reciprocity (licensure based on evidence of having met licensing criteria in another state) |
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Scope of Practice
is defined by whom? |
Defined by the NPA
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Scope of Practice is what ?
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Definition of each level of nursing and what the nurses can do or not do at each level
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The board has developed what?
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“Six-Step Decision-Making Model for Determining Nursing Scope of Practice” to help
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Vocational nursing” means what?
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Vocational nursing” means a directed scope of nursing practice
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“Vocational nursing requires an act of ?
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including the performance of an act that requires specialized judgment and skill,
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“Vocational nursing is based on what?
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the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of vocational nursing.
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“Vocational nursing does not include what? (the nurse cannot do what?)
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The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.
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Vocational nursing involves:
collecting & performing what in a patient? |
A) collecting data and performing focused nursing assessments of the health status of an individual;
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Vocational nursing involves:
planning what for a patient? |
B) participating in the planning of the nursing care needs of an individual;
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Vocational nursing involves:
participating in what for the patient? |
participating in the development and modification of the nursing care plan;
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Vocational nursing involves:
teaching the paitient to promote? |
participating in health teaching and counseling to promote, attain, and maintain the optimum health level of an individual;
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Vocational nursing involves:
evaluate patient's response to ? |
assisting in the evaluation of an individual’s response to a nursing intervention and the identification of an individual’s needs; and
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Vocational nursing involves:
continuing ed. ? |
engaging in other acts that require education and training, as prescribed by board rules and policies, commensurate with the nurse’s experience, continuing education, and demonstrated competency.
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are the student nurses held to the same standards as a licensed nurse?
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yes
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student nurses must preform task how?
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Perform a task with the same outcome to the patient
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student is responsible for what when giving care?
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Student is legally responsible for his/her own actions or inaction
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what must the student know about the state?
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Students must consult with their instructors
Students must know the NPA of their state |
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the students must not do what to remian legal?
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tudents must not act out of their scope of practice in which they are practicing to remain legal
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Accountability
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taking responsibility for one’s actions.
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Professional accountability
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nurse’s responsibility to meet the health care needs of the patient in a safe and caring way.
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Delegation
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assignment of duties to another person
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Standards of care
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defined in nursing procedure books, institutional manuals of policies and procedures or protocols, an nursing journals that outline current skills or techniques
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The Standard of Care is governed by ?
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The nursing care for vocational nursing is governed by Rule 217.11
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Standards of practice is important for what in a lawsuit?
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important in the case of a lawsuit; they help determine whether a nurse practiced appropriately in a situation.
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medical records are what?
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Written collections of information about a person’s health problems, the care provided by health practitioners, and the client’s progress
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where are medical records kept of the patient?
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Forms of the medical records are placed in the client’s chart. (binder or folder)
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who contribute to the client’s medical record ?
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Many members of the health care team contribute to the client’s medical record by charting, recording, or documenting on the agency’s forms
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Confidential
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only those who provide care to the patient need to access this record
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Purpose of Documentation
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Permanent account
¡ Sharing information ¡ Quality assurance ¡ Accreditation ¡ Reimbursement ¡ Education and research ¡ Legal evidence |
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Permanent Record
what is it purpose? |
Serves as a permanent record of a person’s illness or injury
¡ Kept in chronological order front the time of admit to the time of discharge of death |
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Sharing Informationallows what ?
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Allows all members of the heath care team to share information. This prevents duplication of care and promotes the continuity of care
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Quality Assurance
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It provides the institution a means of achieving quality assurance. A sample of the chart is reviewed , if it is found to be deficient, measures are suggested to correct the problem.
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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is what?
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is a private organization that has established criteria reflecting high standards for institutional health care. They inspect health care organizations periodically to make sure that they are living up to the standard set by JCAHO.
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Client Access to Records to do what?
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Clients have the right to view their medical record. How that happens is the decision of the institution.
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What is in each chart?
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Admission Data
¡ Signed consent for treatment ¡ Physician’s or health care provider’s care ¡ Medical history and physician’s physical exam ¡ Nurse’s documentation of ongoing assessments, a plan of care, interventions, and evaluation ¡ Medication records ¡ Physicians progress notes ¡ Progress notes from other disciplines ¡ Laboratory results ¡ Discharge information |
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Methods of Charting
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Narrative charting
¡ Problem-Oriented Medical Records (POMR) § SOAP charting § Focus charting § PIE charting |
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Documentation of the Nursing Process
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Charting organized by diagnosis or problem
¡ Initial assessment each shift ¡ Flow chart and narrative abnormality ¡ Nursing care plan created at admission § Reviewed and updated every 24 hours ¡ Interventions documented on flow sheet or nurse’s notes ¡ Evaluation in nurses notes |
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Narrative Charting involves what?
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Involves writing client information in chronological order.
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Problem-Oriented Medical Records involves what?
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Structured method of documentation that emphasizes the patient’s problems
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Problem-Oriented Medical Records is organized how?
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Organized in a way to correspond to the nursing process and facilitates communication of patient needs
Organized by problem or diagnosis |
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SOAP Charting
is done how? |
S= Subjective data
O= Objective data A= Analysis of data P= Plan of care I= Implementation R=Revision of plan of care |
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Focus Charting is done how?
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Uses the word focus instead of problem, due to the negative connotation of the word problem. This method of charting uses the DAR method. D=Data, A=Analysis, R=Response
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PIE Charting
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P= Problem
I= Intervention E= Evaluation Each problem in this method is given# to correlate the charting with. |
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Source Records
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Each discipline has a separate section in which to record data
Does not organize by patient problem |
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Source Records
advantage is ? |
Advantage is that caregivers are able to easily locate the section they need
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Source Records
diadvantage is ? |
Disadvantage is care is fragmented
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Charting by Exception
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With this method the nurse only charts or elaborates on the abnormal findings in the chart.
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Advantages
Charting by Exception |
Highlights abnormal data and patient trends
Decreases time Eliminates duplication |
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Disadvantages
Charting by Exception |
Development of detailed protocols and procedures
Retraining of staff Data is omitted |
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Computer Charting
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A computer is used to do all charting
This method is most effective when there is a computer terminal at the patient’s bedside. |
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Advantages of Computer Charting
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Information is always legible
§ It automatically records the date and time of the documentation § The abbreviations and terms are consistent with agency approved lists § It eliminates trivia § Omissions are fewer because the computer prompts the nurse to enter specific information § It reduces overtime costs for uncompleted end of shift charting § Electronic data require less storage space and are quickly retrievable |
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Disadvantages of Computer Charting
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The initial expense of purchasing the system and training the employees
§ During a power failure nurses will have to revert to paper charting, until the computers are back online |
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Accuracy in Charting
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Be specific and definite in using words or phrases that convey the meaning you wish
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Brevity in Charting
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Sentences are not necessary
¡ Articles may be omitted ¡ “Patient” may be left out ¡ Acceptable abbreviations may used ¡ If an abnormal or change is noted, then chart it. |
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Nursing Kardex
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quick reference for current information about the client and his or her care
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Flow Sheets
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A form of documentation with sections for recording frequently repeated assessment data
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Indicating Documentation Time
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The use of military time avoids confusion, because no number is ever duplicated, and the labels am and pm, midnight, and noon are not needed
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SBAR Communication
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During handoff communication risk of important information to be lost
¡ SBAR tool was created to help prevent this ¡ Helpful when communicating with physicians due to both fields of learning communicate differently |
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SBAR
S |
Situation: Identify yourself and position, patient’s name and the current situation. Describe what is going on with the patient.
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SBAR
B |
Background: State the relevant history and physical (H&P), physical assessment pertinent to the problem, treatment/clinical course summary and any pertinent changes.
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SBAR
A |
Assessment: Offer your conclusion about the present situation.
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SBAR
R |
Recommendation: Explain what you think needs to be done, what the patient needs and when.
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SBAR
what should you do to clearify info? |
Verify any critical information received, review the history, seek clarification, ask questions, and read back critical test results.
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