NUR 160-Hondros Exam 1/ 123 Questions &
Definitions/ A+.
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)
Page 1 of 13
, 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
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
Page 2 of 13
Definitions/ A+.
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)
Page 1 of 13
, 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
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
Page 2 of 13
