NUR 160-Hondros Exam question with answers
just culture - -workers are protected from disciplinary action when they report
injuries, errors, or near misses
-close-ended question - -What is your name?
-false reassurance - -Everything will be fine
-Why Assess? - -To identify changes in pt condition, to help foresee areas of
concern
-RN - -who does the initial assessment?
-Within 24 hours - -When should an initial assessment be done?
-discharge planning - -What should we pay attention to when a pt is post op knee
replacement and they live on 2nd floor
-Steps of an assessment - -1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
-Correct, then continue - -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 - -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 indifferent)
-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)
-Absent Bowel Sounds - -Auscultate 5 mins per quadrant (Silence means NOTHING)
(20 minute total) assess for an obstruction and notify MD
-Normal IM injection reaction - -Burning at site, itching at site, bruising
-Abnormal IM injection Reaction - -vomiting, constipation, dry mouth, rash
(systemic)
-TB testing - -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 - -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
-At risk for TB - -nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
-Hyperglycemia - -hot and dry-sugar high
-Hypoglycemia - -cold and clammy-needs some candy
-Symptoms of Hyperglycemia - -extreme thirst, frequent urination, dry skin, hunger,
blurred vision, drowsiness, nausea
-Symptoms of Hypoglycemia - -shaking, tachycardia, sweating, anxious, dizzy,
hunger, impaired vision, weakness, fatigue, headaches, irritable
-insulin - -NPH-longer lasting (cloudy)
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
-Vision Assessment - -PERRLA, peripheral testing, snellen chart, Hx (changes in
vision?, dark spots?, flashes?, issues in certain lighting?)
-Vision pt education - -Certain drops can burn eyes, burning is better than being
blind (miotics)
-Hearing interventions - -1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
-Hearing Treatment - -audiology
-Cataract Assessment - -1. dimness
2. misty vision
3. blurriness (milky haze)
-Glaucoma - -High IOP
-Timolol - -Glaucoma Tx
just culture - -workers are protected from disciplinary action when they report
injuries, errors, or near misses
-close-ended question - -What is your name?
-false reassurance - -Everything will be fine
-Why Assess? - -To identify changes in pt condition, to help foresee areas of
concern
-RN - -who does the initial assessment?
-Within 24 hours - -When should an initial assessment be done?
-discharge planning - -What should we pay attention to when a pt is post op knee
replacement and they live on 2nd floor
-Steps of an assessment - -1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
-Correct, then continue - -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 - -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 indifferent)
-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)
-Absent Bowel Sounds - -Auscultate 5 mins per quadrant (Silence means NOTHING)
(20 minute total) assess for an obstruction and notify MD
-Normal IM injection reaction - -Burning at site, itching at site, bruising
-Abnormal IM injection Reaction - -vomiting, constipation, dry mouth, rash
(systemic)
-TB testing - -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 - -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
-At risk for TB - -nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
-Hyperglycemia - -hot and dry-sugar high
-Hypoglycemia - -cold and clammy-needs some candy
-Symptoms of Hyperglycemia - -extreme thirst, frequent urination, dry skin, hunger,
blurred vision, drowsiness, nausea
-Symptoms of Hypoglycemia - -shaking, tachycardia, sweating, anxious, dizzy,
hunger, impaired vision, weakness, fatigue, headaches, irritable
-insulin - -NPH-longer lasting (cloudy)
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
-Vision Assessment - -PERRLA, peripheral testing, snellen chart, Hx (changes in
vision?, dark spots?, flashes?, issues in certain lighting?)
-Vision pt education - -Certain drops can burn eyes, burning is better than being
blind (miotics)
-Hearing interventions - -1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
-Hearing Treatment - -audiology
-Cataract Assessment - -1. dimness
2. misty vision
3. blurriness (milky haze)
-Glaucoma - -High IOP
-Timolol - -Glaucoma Tx
