NUR 160-HONDROS EXAM 1
WITH CORRECT ANSWERS
just culture - answer- workers are protected from disciplinary action when they report
injuries, errors, or near misses
close-ended question - answer- What is your name?
false reassurance - answer- Everything will be fine
Why Assess? - answer- To identify changes in pt condition, to help foresee areas of
concern
RN - answer- who does the initial assessment?
Within 24 hours - answer- When should an initial assessment be done?
discharge planning - 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 - answer- 1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
, 5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - 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 - answer- Subjective then Objective (helps to identify ares of focus)
Inspect airway, auscultate lungs - answer- If pt c/o sore throat or recent cold
Serous Drainage - answer- Clear(Good or indifferent)
Sanginous Drainage - answer- Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - answer- Pink-mix of blood and serous(This is ok)
Purulent Drainage - answer- Puss (assess for infection and notify MD)
Absent Bowel Sounds - answer- Auscultate 5 mins per quadrant (Silence means
NOTHING) (20 minute total) assess for an obstruction and notify MD
Normal IM injection reaction - answer- Burning at site, itching at site, bruising
Abnormal IM injection Reaction - answer- vomiting, constipation, dry mouth, rash
(systemic)
WITH CORRECT ANSWERS
just culture - answer- workers are protected from disciplinary action when they report
injuries, errors, or near misses
close-ended question - answer- What is your name?
false reassurance - answer- Everything will be fine
Why Assess? - answer- To identify changes in pt condition, to help foresee areas of
concern
RN - answer- who does the initial assessment?
Within 24 hours - answer- When should an initial assessment be done?
discharge planning - 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 - answer- 1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
, 5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - 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 - answer- Subjective then Objective (helps to identify ares of focus)
Inspect airway, auscultate lungs - answer- If pt c/o sore throat or recent cold
Serous Drainage - answer- Clear(Good or indifferent)
Sanginous Drainage - answer- Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - answer- Pink-mix of blood and serous(This is ok)
Purulent Drainage - answer- Puss (assess for infection and notify MD)
Absent Bowel Sounds - answer- Auscultate 5 mins per quadrant (Silence means
NOTHING) (20 minute total) assess for an obstruction and notify MD
Normal IM injection reaction - answer- Burning at site, itching at site, bruising
Abnormal IM injection Reaction - answer- vomiting, constipation, dry mouth, rash
(systemic)
