Nur 160 exam 1 | Questions and
Answers | Latest Version
2024/2025
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
Answers | Latest Version
2024/2025
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
