NUR 160-Hondros Exam 1 with 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
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
