Nur 160 Exam- 195 Questions with Verified
100% Correct Answers
when teaching diabetes what is one thing you want to teach them? - Answer avoid
heating pads, wear shoes, heated blankets, don't cut their own nails, dry location, check
feet daily
orthopenic position - Answer crossed arms on side table
if there is an abnormal finding during an assessment what do you do? - Answer further
assessment (focused assessment)
Neurological focused assessment - Answer Glasgow coma scale
level of consciousness(1-person,2-person and place, 3-person, place, and time, 4-
person, place, time, and purpose)
motor function(smile, frown, puff cheeks)ROM
PERLA(pupils, equal, round, reactive, light, accommodation)
cardiac focused assessment - Answer 60-100
caratoid pulse( never press hard or use both hands. used for unconsious pts)
brachial(fore arm)
radial(inner wrist. common pulse)
Apical( 5th innercostal space)listen 60 sec
Femoral(thigh)
popitiel(behind knee)
posterior tibial(ankle)
Dorsal pedis(top of foot)
,slow - Answer brady cardia
fast - Answer tachy cardia
Respiratory Focused Assessment - Answer 12-20
count respirations
95-100%
if patient o2 level is 89%, give them 2L of oxygen
have them sit at 90 degrees
RL(3 lobes)
LL(2 lobes+heart)
crackles - Answer bubble sounds
rales
wheezing - Answer sure sounds
GI Focused Assessment - Answer assess for any masses, bruising, etc
Inspect, Auscultate, Palpate
Always listen for one minute per quad
always listen before palpating because bowel sounds can be disturbed or altered
decreased bowel sounds - Answer constipation
increased bowel sounds - Answer diarrhea
, Integumentary focused assessment - Answer 98.6
Braden scale
tugor-elasticity
no redness, lesions, masses, or discoloration
serous drainage - Answer clear, watery plasma
purulent drainage - Answer Thick, yellow, green, tan, or brown drainage
pus
Seroussanguineous drainage - Answer watery, pink, pale, red
sanguineous drainage - Answer bloody drainage
Stage 1 pressure ulcer - Answer intact skin with nonblanchable redness
stage 2 pressure ulcer - Answer partial thickness skin loss involving epidermis, dermis, or
both
stage 3 pressure ulcer - Answer full thickness tissue loss with visible fat
stage 4 pressure ulcer - Answer Full-thickness tissue loss with exposed bone, muscle, or
tendon
urology - Answer incontinences
