Hondros Final Exam Study Guide NUR 160 - Complete Solutions Updated

Hondros Final Exam Study Guide NUR 160 - Complete Solutions Updated just culture - answer - workers are protected from disciplinary action when they report injuries, errors, or near misses close-ended question - answer - What is your name? false reassurance - answer - Everything will be fine Why Assess? - answer - To identify changes in pt condition, to help foresee areas of concern RN - answer - who does the initial assessment? Within 24 hours - answer - When should an initial assessment be done? discharge planning - answer - What should we pay attention to when a pt is post op knee replacement and they live on 2nd floor Steps of an assessment - answer - 1. Introduce self 2. Explain procedure 3. wash hands 4. Identify pt 5. Provide privacy 6. Inspect, auscultate, palpate Correct, then continue - answer - If a concern arises during assessment (Ex: pt c/o SOB. Sit up, apply O2 or check tubing, teach inhale through nose, exhale through mouth) Order of assessmet - answer - Subjective then Objective (helps to identify ares of focus) Inspect airway, auscultate lungs - answer - If pt c/o sore throat or recent cold Serous Drainage - answer - Clear(Good or indifferent) Sanginous Drainage - answer - Blood-red(a little is ok, alot is bad) Serosanginous Drainage - answer - Pink-mix of blood and serous(This is ok) Purulent Drainage - answer - Puss (assess for infection and notify MD) Absent Bowel Sounds - answer - Auscultate 5 mins per quadrant (Silence means NOTHING) (20 minute total) assess for an obstruction and notify MD Normal IM injection reaction - answer - Burning at site, itching at site, bruising Abnormal IM injection Reaction - answer - vomiting, constipation, dry mouth, rash (systemic) TB testing - answer - 1. Must be read 48-72 hrs (assessed) 2. Document date, time of injection and reading, as well as result 3. Mild swelling is normal TB result-negative - answer - 10mm- healthcare workers are a strict 10 TB result-positive - answer - red, raised (induration) Positive TB result - answer - This means that the person has been exposed to TB At risk for TB - answer - nursing homes, jails, homeless, certain meds, some other countries, healthcare workers Hyperglycemia - answer - hot and dry-sugar high Hypoglycemia - answer - cold and clammy-needs some candy Symptoms of Hyperglycemia - answer - extreme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea Symptoms of Hypoglycemia - answer - shaking, tachycardia, sweating, anxious, dizzy, hunger, impaired vision, weakness, fatigue, headaches, irritable insulin - answer - NPH-longer lasting (cloudy) Regular- faster acting (clear) Order of Insulin Draw - answer - cloudy(air), clear(air),clear(insulin), cloudy(insulin) 70-110 - answer - Normal BS Vision Intervention - answer - Annual Eye Exam Vision Assessment - answer - PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark spots?, flashes?, issues in certain lighting?) Vision pt education - answer - Certain drops can burn eyes, burning is better than being blind (miotics) Hearing interventions - answer - 1. Face to face 2. Speak clearly, slowly and directly 3. Eliminate background noise Hearing Treatment - answer - audiology Cataract Assessment - answer - 1. dimness 2. misty vision 3. blurriness (milky haze) Glaucoma - answer - High IOP Timolol - answer - Glaucoma Tx ARMD risks - answer - 1. depression 2. ignoring Sx 3. injuries, falls, accidents, mobility ARMD sight - answer - Loss of central vision- can see on side(may place things to one side or other) Glaucoma Sight - answer - Loss of peripheral vision-side vision Deafness Intervention - answer - hearing aid care Hearing aid care - answer - Do not wash/submerge hearing aids. Turn off when not in use, open battery door Timolol side effects - answer - Beta Blocker-slows heart down, watch for SOB Malignant Tumors - answer - Irregular, Immobile, hard upon palpation, ususally not painful Important f