NUR 160-Hondros Exam 1 Test Questions with Answers Rated A
workers are protected from disciplinary action when they
just culture
report injuries, errors, or near misses
close-ended question What is your name?
false reassurance Everything will be fine
To identify changes in pt condition, to help foresee areas
Why Assess?
of concern
RN who does the initial assessment?
Within 24 hours When should an initial assessment be done?
What should we pay attention to when a pt is post op knee
discharge planning
replacement and they live on 2nd floor
1. Introduce self
2. Explain procedure
3. wash hands
Steps of an assessment
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
If a concern arises during assessment (Ex: pt c/o SOB. Sit
Correct, then continue 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 inditterent)
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)
Auscultate 5 mins per quadrant (Silence means NOTHING)
Absent Bowel Sounds
(20 minute total) assess for an obstruction and notify MD
1/9
, NUR 160-Hondros Exam 1 Test Questions with Answers Rated A
Normal IM injection reaction Burning at site, itching at site, bruising
Abnormal IM injection Reaction vomiting, constipation, dry mouth, rash (systemic)
1. Must be read 48-72 hrs (assessed)
2. Document date, time of injection and reading, as well
TB testing
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
nursing homes, jails, homeless, certain meds, some other
At risk for TB
countries, healthcare workers
Hyperglycemia hot and dry-sugar high
Hypoglycemia cold and clammy-needs some candy
extreme thirst, frequent urination, dry skin, hunger,
Symptoms of Hyperglycemia
blurred vision, drowsiness, nausea
shaking, tachycardia, sweating, anxious, dizzy, hunger, im-
Symptoms of Hypoglycemia
paired vision, weakness, fatigue, headaches, irritable
NPH-longer lasting (cloudy)
insulin
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
PERRLA, peripheral testing, snellen chart, Hx (changes in
Vision Assessment
vision?, dark spots?, flashes?, issues in certain lighting?)
Certain drops can burn eyes, burning is better than being
Vision pt education
blind (miotics)
Hearing interventions 2/9
workers are protected from disciplinary action when they
just culture
report injuries, errors, or near misses
close-ended question What is your name?
false reassurance Everything will be fine
To identify changes in pt condition, to help foresee areas
Why Assess?
of concern
RN who does the initial assessment?
Within 24 hours When should an initial assessment be done?
What should we pay attention to when a pt is post op knee
discharge planning
replacement and they live on 2nd floor
1. Introduce self
2. Explain procedure
3. wash hands
Steps of an assessment
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
If a concern arises during assessment (Ex: pt c/o SOB. Sit
Correct, then continue 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 inditterent)
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)
Auscultate 5 mins per quadrant (Silence means NOTHING)
Absent Bowel Sounds
(20 minute total) assess for an obstruction and notify MD
1/9
, NUR 160-Hondros Exam 1 Test Questions with Answers Rated A
Normal IM injection reaction Burning at site, itching at site, bruising
Abnormal IM injection Reaction vomiting, constipation, dry mouth, rash (systemic)
1. Must be read 48-72 hrs (assessed)
2. Document date, time of injection and reading, as well
TB testing
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
nursing homes, jails, homeless, certain meds, some other
At risk for TB
countries, healthcare workers
Hyperglycemia hot and dry-sugar high
Hypoglycemia cold and clammy-needs some candy
extreme thirst, frequent urination, dry skin, hunger,
Symptoms of Hyperglycemia
blurred vision, drowsiness, nausea
shaking, tachycardia, sweating, anxious, dizzy, hunger, im-
Symptoms of Hypoglycemia
paired vision, weakness, fatigue, headaches, irritable
NPH-longer lasting (cloudy)
insulin
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
PERRLA, peripheral testing, snellen chart, Hx (changes in
Vision Assessment
vision?, dark spots?, flashes?, issues in certain lighting?)
Certain drops can burn eyes, burning is better than being
Vision pt education
blind (miotics)
Hearing interventions 2/9
