NUR 160 Hondros Exam 1 __., __., __., __., __.,
with complete Solutions. __., __.,
When should an initial assessment be done?
__., __., __., __., __., __., __.,__., __., Within 24 hours __., __.,
For severe pain, schedule II, binds to opiate pain receptors, BBB
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Morphine
moderate to high pain, acetaminophen with oxycodone, BBB
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Percocet
moderate pain, acetaminophen with hydrocodone
__., __., __., __., __.,__., __., Norco
What should we pay attention to when a pt is post op knee
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replacement and they live on 2nd floor
., discharge planning
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workers are protected from disciplinary action when they report injuries,
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errors, or near misses
__., __.,just culture
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What is your name?
__., __., __., __.,__., close-ended question
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Everything will be fine __., __., __., __.,__., __., false reassurance __.,
,To identify changes in pt condition, to help foresee areas of concern
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Why Assess?__., __.,
who does the initial assessment?
__., __., __., __., __.,__., __., RN
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
__., __., __., __.,__., __., Steps of an assessment __., __., __.,
If a concern arises during assessment (Ex: pt c/o SOB. Sit up, apply O2
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or check tubing, teach inhale through nose, exhale through mouth)
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Correct, then continue
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Subjective then Objective (helps to identify ares of focus)
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assessmet
.,
If pt c/o sore throat or recent cold
__., __., __., __., __., __., __., __.,__., Inspect airway, auscultate lungs
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Clear(Good or indifferent) __., __., __.,__., __., Serous Drainage __.,
, Blood-red(a little is ok, alot is bad) __., __., __., __., __., __., __.,__., Sanginous Drainage
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Pink-mix of blood and serous(This is ok)
__., __., __., __., __., __., __.,__., Serosanginous Drainage
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Puss (assess for infection and notify MD)
__., __., __., __., __., __., __.,__., __., Purulent Drainage __.,
Auscultate 5 mins per quadrant (Silence means NOTHING) (20 minute t
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otal) assess for an obstruction and notify MD
__., Absent Bowel Sound
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s
Burning at site, itching at site, bruising
__., __., __., __., __., __., __.,__., Normal IM injection reactio
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n
vomiting, constipation, dry mouth, rash (systemic)
__., __., __., __., __., __.,__., Abnormal IM inj
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ection Reaction __.,
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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3. Mild swelling is normal
__., __., __., __., __.,__., TB testing
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10mm- healthcare workers are a strict 10
__., __., __., __., __., __., __.,__., __., TB result-negative
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red, raised (induration)
__., __., __.,__., __., TB result-positive
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