Documentation/Rights
What are the 6 rights of medication administration?
What is the Right person, Right Medication, Right dose, Right time/date, Right route, Right documentation
T/F We can “Hold” medications without a providers orders
What is False. We can not Hold or "H" a medication without an order.
This person fills out the medication error report when an error occurs?
Who is the person that found the error
Minor scrapes/cuts should be treated this way:
What is wash with soap/water, apply antibiotic ointment, apply bandage
You have a fever of 100.9 and a congested cough. You call into work ill. What is required before you can return to work?
What is fever free without medication for 24 hours and clearance from PCS Nursing
Clara reports a headache and requests Tylenol from the RSO list. Where do you document this?
What is both the PRN MAR and Health Notes.
What are we required to do after every administration of an as needed or PRN medication?
What is document a follow up response - Did it work?
When passing the 8am medications you notice that you gave the last pill out of the bottle. What do you do?
Check the refill bin, Check the pharmacy reorder form, Call in the medication
How to position a person to control a nose bleed
What is Sitting upright with head and body leaning slightly forward.
What are 3 common symptoms of a urinary tract infection?
Burning with urination, frequent urination, Blood in the urine, foul odor
A person served has loose stools and has a scheduled dose of Colace in 15 minutes. The order reads: Colace 100mg oral every HS constipation. What are your next steps?
What is call supervisor/Nursing for direction unless order specifically states to hold if diarrhea/loose stools
When administering ear drops, how would you pull the ear to straighten the ear canal?
What is up and back
These medications need to be stored separate in the medication cabinet
What are Orals and topicals
These are the first steps for treating a MINOR burn:
What are Cool the burn under cool (Not cold) water and cover burn with a bandage
hunger, shaking, sweating, dizziness, rapid heartbeat, mood changes, irritability or anxiety, headache, difficulty sleeping, skin tingling, blurry vision, trouble thinking clearly or concentrating, loss of consciousness, seizure, or coma
What needs to be written on the envelope when packaging medications for a person served?
1. The Person Served name
2. Medication and dosage
3. Directions for giving
4. Time/date
5. Rx Number
What do you do if a medication order calls for ½ tablet and all you have is full tablets on hand
What is call supervisor who will then call nursing. Only Nursing or pharmacy can split tablets.
At 8pm you notice that the 8am medications were not initialed off as given. What do you do?
What is call the staff that was responsible for the 8am medication pass to see if they were administered. If not administered fill out medication error form and notify supervisor. If meds were given but not initialed: 48 hours to return and complete initialing or documentation error.
This is the first thing you should do to stop bleeding
What is apply direct pressure
What are 2 symptoms of a stroke?
Numbness/weakness in face/limbs on one side of the body, slurred speech, confusion, facial drooping, headache
Johnny has a prescribed cream at HS that is to be applied to his groin rash that has been causing him a lot of discomfort. When you attempt to administer the cream Johnny adamantly refuses despite multiple attempts and explanation of the cream's importance. What do you do next?
What is document the medication refusal on the MAR with an "R" and explanation on the back. May need to update supervisor/Nursing. Document in health notes.
You have double staffing for 2 hours in the morning for 4 people served. Each staff provide cares to 2 people each. Who administers each of these people’s medications?
1 Staff member should be designated to administer all medications scheduled that shift including PRN's.
Jack has medications ordered for 7am on an empty stomach. You notice when clearing breakfast that the med cup still had his pill in it. What do you do and why?
What is: Contact Supervisor/Nursing. Fill out med error form and worksheet.
Why? He did not get his medication on an empty stomach as ordered and has now eaten breakfast.
You left medications unattended and did not watch or verify they took them
Always watch the person swallow the medications when administering and never leave medications unattended.
The document you should follow for instruction on when to call 911 for a person served having a seizure. (With a known seizure disorder)
What is the seizure protocol
You find Steve sitting in his recliner chair and notice his arms, legs and head are shaking/twitching. You know that Steve has had seizures in the past but unsure what to do. This is where you will find a copy of his seizure protocol to determine if you need to call 911
What is in the MAR binder under his tab/name and in his Medical chart
June has requested some Tylenol for her chronic left shoulder pain. All she has in her bin is Acetaminophen. You think you are pretty sure this is the same medication. Which right is this referring to and where would you look to be sure you are following that right and protecting it?
What is the right medication
What is Go to the Side Effects binder and locate the medication explanation handout. Locate the generic and Trade name of this medication to verify the medication is in fact the same.
How much time is needed before and after meals in order to give a medication on an empty stomach
What is 1 hour before meals and 2 hours after
At the 8am med pass you notice the medications from the night before were not initialed off. After calling staff and investigating you find that Anna had been given Jims medications for 8pm and Jim had not received any medications at that time. Which of Anna's 6 rights have been violated in this scenario?
What is Right person, Right Med, Documentation
A ____ ______ is an unwanted undesirable effect that can occur when taking a drug or medication
What is a side effect
Beth was diagnosed with a UTI and prescribed an antibiotic 3 times daily x7 days. The times on the MAR for this med are 8am - 2pm - 8pm. The medication is picked up at 4pm. Do you give this medication as soon as we receive it or wait until the next scheduled dose time to start?
why?
Yes, we give the first dose as soon as we receive it.
Starting the antibiotic ASAP is crutial for preventing sepsis and/or worsening infection
When to perform your 3 checks during medication administration
1. When removing the medication from the Bin
2. Before opening or removing the medication
3. After pouring med and before administering the medication to the person
Jane D is requesting you leave the cup with her AM medications on the table after you had already dished them and she will take them when she gets done with her makeup.
What do you do?
What is Explain to Jane that you cannot leave medications unattended. You must watch the person take all medications.
At Breakfast Billy states he hasn't had a BM for 3 days. He is requesting something for it. What medication on the RSO list can you give him? (See RSO Handout)
Nothing, The RSO states MOM 1ounce oral at BEDTIME as needed. It is breakfast time.
This contains printed information on potential side effects of medications our people served are administered
What is the Medication side effects binder
Karen has started a new antibiotic today for her UTI. She now is complaining of her tongue feeling itchy and “Bigger” and you notice her lips and face are swollen.
1. What might Karen be experiencing?
2. what do you do?
1. What is Anaphylaxis or Severe allergic reaction
2. Call 911 and Use Epi-pen if person has one available or Call 911 immediately
Jimmy has an order for Ativan 1mg po qhs PRN – Anxiety
After his morning shower he requested an Ativan.
How do you document this on the MAR?
You don’t document on MAR. Order states qhs PRN so can not be given after his morning shower.
Its 3pm shift change. The AM staff reported to you that Bill requested a Tylenol for a 4/10 headache an hour ago. She gave bill 325mg of Tylenol from the RSO list at 2pm. She transcribed the order from the RSO list onto the PRN MAR in an empty box at the top of page as follows:
Tylenol 325mg 2 tablets oral every 4 hours as needed for pain or Temp over 100.6
She documented giving the PRN including the Date/Time/Medication/Dosage/Route/Reason and Signature
What is important that you do regarding this PRN administration?
Fill out medication Error report.
The order for RSO Tylenol states Tylenol 325mg 2 tablets oral every 4 hours as needed. Bill was only given 1 tablet of Tylenol 325 mg when order is for 2 tablets.
You come on shift on 6/11/25 at 8am and the night staff report that Jim bob has had a runny nose/cold symptoms for 2 days. He was given Claritin from the RSO’s the day before. He continues to have a runny nose/cold symptoms. You see that the RSO states:
Claritin 10mg 1 tablet oral once daily as needed for cold symptoms.
The last Claritin entry on the PRN sheet reads:
6/10/25 7:00 Claritin 10 mg 1 tab oral cold symptoms. J. Doe DSP
Should you give him another dose of Claritin?
NO
There is no AM or PM on the last entry so you don't know if it has been 24 hours since his last dose. The person that administered the last dose must be contacted to verify when his last dose was received.
Billy has a deep cut on his arm and has heavy bleeding. You notice that the gauze pressure dressing that you have over the cut is saturated. What do you do?
You can add more gauze but NEVER remove the original dressing. Doing so may increase the rate of bleeding.
What are the 3 things that a psychotropic medication can alter in a person that requires us to have an informed consent or "special consent" before we can administer them?
What is Mind, Mood, or Behavior