NUR 160-Hondros Exam 1|123
Questions and Answers
just culture - -workers are protected from disciplinary action when they
report injuries, errors, or near misses
- close-ended question - -What is your name?
- false reassurance - -Everything will be fine
- Why Assess? - -To identify changes in pt condition, to help foresee areas
of concern
- RN - -who does the initial assessment?
- Within 24 hours - -When should an initial assessment be done?
- discharge planning - -What should we pay attention to when a pt is post
op knee replacement and they live on 2nd floor
- Steps of an assessment - -1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
- Correct, then continue - -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 - -Subjective then Objective (helps to identify ares of
focus)
- Inspect airway, auscultate lungs - -If pt c/o sore throat or recent cold
- Serous Drainage - -Clear(Good or indifferent)
- Sanginous Drainage - -Blood-red(a little is ok, alot is bad)
- Serosanginous Drainage - -Pink-mix of blood and serous(This is ok)
- Purulent Drainage - -Puss (assess for infection and notify MD)
, - Absent Bowel Sounds - -Auscultate 5 mins per quadrant (Silence means
NOTHING) (20 minute total) assess for an obstruction and notify MD
- Normal IM injection reaction - -Burning at site, itching at site, bruising
- Abnormal IM injection Reaction - -vomiting, constipation, dry mouth, rash
(systemic)
- TB testing - -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 - -10mm- healthcare workers are a strict 10
- TB result-positive - -red, raised (induration)
- Positive TB result - -This means that the person has been exposed to TB
- At risk for TB - -nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
- Hyperglycemia - -hot and dry-sugar high
- Hypoglycemia - -cold and clammy-needs some candy
- Symptoms of Hyperglycemia - -extreme thirst, frequent urination, dry skin,
hunger, blurred vision, drowsiness, nausea
- Symptoms of Hypoglycemia - -shaking, tachycardia, sweating, anxious,
dizzy, hunger, impaired vision, weakness, fatigue, headaches, irritable
- insulin - -NPH-longer lasting (cloudy)
Regular- faster acting (clear)
- Order of Insulin Draw - -cloudy(air), clear(air),clear(insulin), cloudy(insulin)
- 70-110 - -Normal BS
- Vision Intervention - -Annual Eye Exam
- Vision Assessment - -PERRLA, peripheral testing, snellen chart, Hx
(changes in vision?, dark spots?, flashes?, issues in certain lighting?)
- Vision pt education - -Certain drops can burn eyes, burning is better than
being blind (miotics)
Questions and Answers
just culture - -workers are protected from disciplinary action when they
report injuries, errors, or near misses
- close-ended question - -What is your name?
- false reassurance - -Everything will be fine
- Why Assess? - -To identify changes in pt condition, to help foresee areas
of concern
- RN - -who does the initial assessment?
- Within 24 hours - -When should an initial assessment be done?
- discharge planning - -What should we pay attention to when a pt is post
op knee replacement and they live on 2nd floor
- Steps of an assessment - -1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
- Correct, then continue - -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 - -Subjective then Objective (helps to identify ares of
focus)
- Inspect airway, auscultate lungs - -If pt c/o sore throat or recent cold
- Serous Drainage - -Clear(Good or indifferent)
- Sanginous Drainage - -Blood-red(a little is ok, alot is bad)
- Serosanginous Drainage - -Pink-mix of blood and serous(This is ok)
- Purulent Drainage - -Puss (assess for infection and notify MD)
, - Absent Bowel Sounds - -Auscultate 5 mins per quadrant (Silence means
NOTHING) (20 minute total) assess for an obstruction and notify MD
- Normal IM injection reaction - -Burning at site, itching at site, bruising
- Abnormal IM injection Reaction - -vomiting, constipation, dry mouth, rash
(systemic)
- TB testing - -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 - -10mm- healthcare workers are a strict 10
- TB result-positive - -red, raised (induration)
- Positive TB result - -This means that the person has been exposed to TB
- At risk for TB - -nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
- Hyperglycemia - -hot and dry-sugar high
- Hypoglycemia - -cold and clammy-needs some candy
- Symptoms of Hyperglycemia - -extreme thirst, frequent urination, dry skin,
hunger, blurred vision, drowsiness, nausea
- Symptoms of Hypoglycemia - -shaking, tachycardia, sweating, anxious,
dizzy, hunger, impaired vision, weakness, fatigue, headaches, irritable
- insulin - -NPH-longer lasting (cloudy)
Regular- faster acting (clear)
- Order of Insulin Draw - -cloudy(air), clear(air),clear(insulin), cloudy(insulin)
- 70-110 - -Normal BS
- Vision Intervention - -Annual Eye Exam
- Vision Assessment - -PERRLA, peripheral testing, snellen chart, Hx
(changes in vision?, dark spots?, flashes?, issues in certain lighting?)
- Vision pt education - -Certain drops can burn eyes, burning is better than
being blind (miotics)
