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