NUR 160-Hondros Exam 1 with correct |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answers
just culture - correct answer✔✔workers are protected from disciplinary action when they
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report injuries, errors, or near misses |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
close-ended question - correct answer✔✔What is your name? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
false reassurance - correct answer✔✔Everything will be fine
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Why Assess? - correct answer✔✔To identify changes in pt condition, to help foresee areas of
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concern
RN - correct answer✔✔who does the initial assessment?
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Within 24 hours - correct answer✔✔When should an initial assessment be done?
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discharge planning - correct answer✔✔What should we pay attention to when a pt is post op
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knee replacement and they live on 2nd floor
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Steps of an assessment - correct answer✔✔1. Introduce self
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2. Explain procedure
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3. wash hands
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4. Identify pt
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5. Provide privacy
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6. Inspect, auscultate, palpate
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, Correct, then continue - correct answer✔✔If a concern arises during assessment (Ex: pt c/o
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SOB. Sit up, apply O2 or check tubing, teach inhale through nose, exhale through mouth)
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Order of assessmet - correct answer✔✔Subjective then Objective (helps to identify ares of
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focus)
Inspect airway, auscultate lungs - correct answer✔✔If pt c/o sore throat or recent cold
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Serous Drainage - correct answer✔✔Clear(Good or indifferent)
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Sanginous Drainage - correct answer✔✔Blood-red(a little is ok, alot is bad) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Serosanginous Drainage - correct answer✔✔Pink-mix of blood and serous(This is ok) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Purulent Drainage - correct answer✔✔Puss (assess for infection and notify MD)
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Absent Bowel Sounds - correct answer✔✔Auscultate 5 mins per quadrant (Silence means
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NOTHING) (20 minute total) assess for an obstruction and notify MD |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Normal IM injection reaction - correct answer✔✔Burning at site, itching at site, bruising
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Abnormal IM injection Reaction - correct answer✔✔vomiting, constipation, dry mouth, rash
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(systemic)
TB testing - correct answer✔✔1. Must be read 48-72 hrs (assessed)
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2. Document date, time of injection and reading, as well as result
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answers
just culture - correct answer✔✔workers are protected from disciplinary action when they
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
report injuries, errors, or near misses |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
close-ended question - correct answer✔✔What is your name? |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
false reassurance - correct answer✔✔Everything will be fine
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Why Assess? - correct answer✔✔To identify changes in pt condition, to help foresee areas of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
concern
RN - correct answer✔✔who does the initial assessment?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Within 24 hours - correct answer✔✔When should an initial assessment be done?
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
discharge planning - correct 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 - correct answer✔✔1. Introduce self
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2. Explain procedure
|||\\\ |||\\\
3. wash hands
|||\\\ |||\\\
4. Identify pt
|||\\\ |||\\\
5. Provide privacy
|||\\\ |||\\\
6. Inspect, auscultate, palpate
|||\\\ |||\\\ |||\\\
, Correct, then continue - correct 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 - correct answer✔✔Subjective then Objective (helps to identify ares of
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
focus)
Inspect airway, auscultate lungs - correct answer✔✔If pt c/o sore throat or recent cold
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Serous Drainage - correct answer✔✔Clear(Good or indifferent)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Sanginous Drainage - correct answer✔✔Blood-red(a little is ok, alot is bad) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Serosanginous Drainage - correct answer✔✔Pink-mix of blood and serous(This is ok) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Purulent Drainage - correct answer✔✔Puss (assess for infection and notify MD)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Absent Bowel Sounds - correct answer✔✔Auscultate 5 mins per quadrant (Silence means
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
NOTHING) (20 minute total) assess for an obstruction and notify MD |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Normal IM injection reaction - correct answer✔✔Burning at site, itching at site, bruising
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Abnormal IM injection Reaction - correct answer✔✔vomiting, constipation, dry mouth, rash
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(systemic)
TB testing - correct answer✔✔1. Must be read 48-72 hrs (assessed)
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2. Document date, time of injection and reading, as well as result
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