NUR 160-HONDROS EXAM 1
justlculture l-lworkerslarelprotectedlfromldisciplinarylactionlwhenltheylreportlinjuries,lerrors,lorlnearlmisses
close-endedlquestionl-lWhatlislyourlname?
false lreassurancel-lEverythinglwill lbelfine
WhylAssess?l- lTolidentifylchangeslinlptlcondition,ltolhelplforesee lareasloflconcern
RNl-lwholdoeslthelinitiallassessment?
Withinl24lhoursl-lWhenlshouldlanlinitial lassessmentlbeldone?
discharge lplanningl-
l Whatl should lwel pay l attentionl tol whenl alptlisl postl opl knee lreplacementlandlthey llivel onl2ndl floor
Stepsloflanlassessmentl-l1.lIntroducelself
2.lExplainlprocedure
3.lwashlhands
4.lIdentifylpt
5.lProvide lprivacy
6.lInspect,lauscultate,lpalpate
Correct,lthenlcontinuel-
l If l al concern larises lduringlassessmentl (Ex:lptlc/olSOB. lSitl up, lapply lO2l orlcheck l tubing, lteachlinhale lthrough ln
ose,lexhalelthroughlmouth)
Orderloflassessmetl-lSubjectivelthenlObjective l(helpsltolidentifylaresloflfocus)
, Inspectlairway,lauscultate llungsl-lIflptlc/olsorelthroatlorlrecentlcold
SerouslDrainagel-lClear(Goodlorlindifferent)
SanginouslDrainage l-lBlood-red(allittle lislok,lalotlislbad)
SerosanginouslDrainage l-lPink-mixloflbloodlandlserous(Thislislok)
PurulentlDrainagel-lPussl(assesslforlinfectionlandlnotifylMD)
AbsentlBowellSoundsl-
l Auscultate l5l mins lperl quadrantl (Silencel means l NOTHING) l(20l minutel total)l assesslforlanlobstructionl andlnot
ifylMD
Normal lIMlinjectionlreactionl-lBurninglatlsite,litchinglatlsite,lbruising
Abnormal lIMlinjectionlReactionl-lvomiting,lconstipation,ldrylmouth,lrashl(systemic)
TBltestingl-l1.lMustlbelreadl48-72lhrsl(assessed)
2.lDocumentldate,ltimeloflinjectionlandlreading,laslwell laslresult
3.lMildlswellinglislnormal
TBlresult-negativel-l10mm-lhealthcare lworkerslare lalstrictl10
TBlresult-positivel-lred,lraisedl(induration)
Positive lTBlresultl-lThislmeanslthatlthelpersonlhaslbeenlexposedltolTB
justlculture l-lworkerslarelprotectedlfromldisciplinarylactionlwhenltheylreportlinjuries,lerrors,lorlnearlmisses
close-endedlquestionl-lWhatlislyourlname?
false lreassurancel-lEverythinglwill lbelfine
WhylAssess?l- lTolidentifylchangeslinlptlcondition,ltolhelplforesee lareasloflconcern
RNl-lwholdoeslthelinitiallassessment?
Withinl24lhoursl-lWhenlshouldlanlinitial lassessmentlbeldone?
discharge lplanningl-
l Whatl should lwel pay l attentionl tol whenl alptlisl postl opl knee lreplacementlandlthey llivel onl2ndl floor
Stepsloflanlassessmentl-l1.lIntroducelself
2.lExplainlprocedure
3.lwashlhands
4.lIdentifylpt
5.lProvide lprivacy
6.lInspect,lauscultate,lpalpate
Correct,lthenlcontinuel-
l If l al concern larises lduringlassessmentl (Ex:lptlc/olSOB. lSitl up, lapply lO2l orlcheck l tubing, lteachlinhale lthrough ln
ose,lexhalelthroughlmouth)
Orderloflassessmetl-lSubjectivelthenlObjective l(helpsltolidentifylaresloflfocus)
, Inspectlairway,lauscultate llungsl-lIflptlc/olsorelthroatlorlrecentlcold
SerouslDrainagel-lClear(Goodlorlindifferent)
SanginouslDrainage l-lBlood-red(allittle lislok,lalotlislbad)
SerosanginouslDrainage l-lPink-mixloflbloodlandlserous(Thislislok)
PurulentlDrainagel-lPussl(assesslforlinfectionlandlnotifylMD)
AbsentlBowellSoundsl-
l Auscultate l5l mins lperl quadrantl (Silencel means l NOTHING) l(20l minutel total)l assesslforlanlobstructionl andlnot
ifylMD
Normal lIMlinjectionlreactionl-lBurninglatlsite,litchinglatlsite,lbruising
Abnormal lIMlinjectionlReactionl-lvomiting,lconstipation,ldrylmouth,lrashl(systemic)
TBltestingl-l1.lMustlbelreadl48-72lhrsl(assessed)
2.lDocumentldate,ltimeloflinjectionlandlreading,laslwell laslresult
3.lMildlswellinglislnormal
TBlresult-negativel-l10mm-lhealthcare lworkerslare lalstrictl10
TBlresult-positivel-lred,lraisedl(induration)
Positive lTBlresultl-lThislmeanslthatlthelpersonlhaslbeenlexposedltolTB
