FPCC Exam 2 Questions and Correct Answers the Latest Update
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Course
FPCC
Institution
FPCC
Documentation
act of recording patient status & care in written form or electronic form , or in a
combination of the 2.
Explain the purposes of documentation
1. communication "continuity of care"
2. legally
3. financially
4. education & quality improvement
Explain how, when, & why to ...
FPCC Exam 2 Questions and
Correct Answers the Latest Update
Documentation
✓ act of recording patient status & care in written form or electronic form , or in a
combination of the 2.
Explain the purposes of documentation
✓ 1. communication "continuity of care"
✓ 2. legally
✓ 3. financially
✓ 4. education & quality improvement
Explain how, when, & why to complete an incident report.
✓ -if an event that happens that isn't consistent with routine care (a never event- pt
developing a pressure ulcer, falling)
✓ -*first assess the pt & the pt's response (vitals, comments, complaints of pain)*
✓ -then inform provider
✓ -provide objective descriptions & subjective comments
✓ -dont include in the chart that you filed an incident report, only write what happened
✓ -if it was a near miss, fill out an incident report to prevent it from happening in the
future.
Discuss the key elements of giving an oral patient report
✓ face-to-face: ideal & most common. keep organized by using SBAR
✓ walking rounds- standard that the handoff should be given at the bedside
✓
✓ taped recording
✓
✓ must include significant info: name, age, diagnosis admitted with
✓ changes in the treatment plan that happened
✓
✓ DO NOT include routine care
What abbreviations can be used in charting?
✓ NONE. never accept an order that has an abbreviation.
Explain the process for verifying or questioning a medical order.
✓ -If an order is written illegibly on a paper order sheet or is entered into the EHR
missing components, contact the provider.
✓ -If you still do not feel comfortable after contacting the provider, you may refuse to
carry it out.
✓ -Inform the chain of command of your refusal.
Nursing admission data forms
✓ used to establish a baseline to monitor change, provides information about the
clients support system, contains the critical information on why the client is there.
Flowsheets/graphic records
✓ use to document assessments and care that are performed frequently, on a
reoccurring schedule, or as a part of unit routines. (Vital signs)
Summarize the process for receiving & documenting verbal & telephone orders
✓ -Carefully identify client.
✓ -Immediately record the order.
✓ -Always repeat the order back & document that too
✓ -Document that you did that/read the order back.
✓ -Question if needed.
✓ -Document TO for telephone order, VO for verbal order.
✓ -If uncomfortable/in a high-risk situation, ask them to repeat order to another nurse.
✓ -The order has to be signed by the person who gave it to you within 24 hours,
electronically or on paper chart.
How much fluid should we encourage our patients to drink daily?
✓ 2200-2700 mL
How is intake of ice chips measured for a patient's I&O?
✓ 1 cup of ice =1/2 a cup of fluid
What are colloids?
✓ larger protein molecules
✓ ex: albumin
Albumin & prealbumin are big factors in predicting ____
✓ -Measure weights first thing in the morning, same time everyday.
✓ -Use same scale
✓ -Void before weighing
✓ -Client needs to be wearing the same thing each time
✓ -Can delegate this
✓ -Client can do this at home, if they are gaining more than *2.2 pounds a day*, they
need to call the provider & check in about what's going on
✓ -1 pound increase is about 500mLs of fluid retention.
We lose about how much fluid in our stool per day?
✓ 100-200 mL/day
How much fluid do we lose through urine a day?
✓ 1500mL/day
What are examples of insensible losses & can they be measured?
✓ -lungs, skin
✓ cannot be measured
Intracellular fluid
✓ contained within the cells.
✓ accounts for 40% of body weight & is essential for cell function & metabolism
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