HONDROS NUR 163 EXAM 1 EXAMPREP TESTED
QUESTIONS AND DETAILED SOLUTIONS
◉ 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)
◉ TB testing.
Answer: 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.
Answer: 10mm- healthcare workers are a strict 10
◉ TB result-positive.
Answer: red, raised (induration)
◉ Positive TB result.
Answer: This means that the person has been exposed to TB
◉ At risk for TB.
Answer: nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
◉ Hyperglycemia.
Answer: hot and dry-sugar high
◉ Hypoglycemia.
Answer: cold and clammy-needs some candy
QUESTIONS AND DETAILED SOLUTIONS
◉ 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)
◉ TB testing.
Answer: 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.
Answer: 10mm- healthcare workers are a strict 10
◉ TB result-positive.
Answer: red, raised (induration)
◉ Positive TB result.
Answer: This means that the person has been exposed to TB
◉ At risk for TB.
Answer: nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
◉ Hyperglycemia.
Answer: hot and dry-sugar high
◉ Hypoglycemia.
Answer: cold and clammy-needs some candy
