NUR 160-Hondros Exam 1 with verified
answers
just culture - CORRECT ANSWERS ✔✔workers are protected from disciplinary
action when they report injuries, errors, or near misses
close-ended question - CORRECT ANSWERS ✔✔What is your name?
false reassurance - CORRECT ANSWERS ✔✔Everything will be fine
Why Assess? - CORRECT ANSWERS ✔✔To identify changes in pt condition, to help
foresee areas of concern
RN - CORRECT ANSWERS ✔✔who does the initial assessment?
Within 24 hours - CORRECT ANSWERS ✔✔When should an initial assessment be
done?
discharge planning - CORRECT ANSWERS ✔✔What should we pay attention to
when a pt is post op knee replacement and they live on 2nd floor
Steps of an assessment - CORRECT ANSWERS ✔✔1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
,5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - CORRECT ANSWERS ✔✔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 - CORRECT ANSWERS ✔✔Subjective then Objective (helps to
identify ares of focus)
Inspect airway, auscultate lungs - CORRECT ANSWERS ✔✔If pt c/o sore throat or
recent cold
Serous Drainage - CORRECT ANSWERS ✔✔Clear(Good or indifferent)
Sanginous Drainage - CORRECT ANSWERS ✔✔Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - CORRECT ANSWERS ✔✔Pink-mix of blood and
serous(This is ok)
Purulent Drainage - CORRECT ANSWERS ✔✔Puss (assess for infection and notify
MD)
Absent Bowel Sounds - CORRECT ANSWERS ✔✔Auscultate 5 mins per quadrant
(Silence means NOTHING) (20 minute total) assess for an obstruction and notify MD
, Normal IM injection reaction - CORRECT ANSWERS ✔✔Burning at site, itching at
site, bruising
Abnormal IM injection Reaction - CORRECT ANSWERS ✔✔vomiting, constipation,
dry mouth, rash (systemic)
TB testing - CORRECT ANSWERS ✔✔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 - CORRECT ANSWERS ✔✔10mm- healthcare workers are a strict
10
TB result-positive - CORRECT ANSWERS ✔✔red, raised (induration)
Positive TB result - CORRECT ANSWERS ✔✔This means that the person has been
exposed to TB
At risk for TB - CORRECT ANSWERS ✔✔nursing homes, jails, homeless, certain
meds, some other countries, healthcare workers
Hyperglycemia - CORRECT ANSWERS ✔✔hot and dry-sugar high
Hypoglycemia - CORRECT ANSWERS ✔✔cold and clammy-needs some candy
answers
just culture - CORRECT ANSWERS ✔✔workers are protected from disciplinary
action when they report injuries, errors, or near misses
close-ended question - CORRECT ANSWERS ✔✔What is your name?
false reassurance - CORRECT ANSWERS ✔✔Everything will be fine
Why Assess? - CORRECT ANSWERS ✔✔To identify changes in pt condition, to help
foresee areas of concern
RN - CORRECT ANSWERS ✔✔who does the initial assessment?
Within 24 hours - CORRECT ANSWERS ✔✔When should an initial assessment be
done?
discharge planning - CORRECT ANSWERS ✔✔What should we pay attention to
when a pt is post op knee replacement and they live on 2nd floor
Steps of an assessment - CORRECT ANSWERS ✔✔1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
,5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - CORRECT ANSWERS ✔✔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 - CORRECT ANSWERS ✔✔Subjective then Objective (helps to
identify ares of focus)
Inspect airway, auscultate lungs - CORRECT ANSWERS ✔✔If pt c/o sore throat or
recent cold
Serous Drainage - CORRECT ANSWERS ✔✔Clear(Good or indifferent)
Sanginous Drainage - CORRECT ANSWERS ✔✔Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - CORRECT ANSWERS ✔✔Pink-mix of blood and
serous(This is ok)
Purulent Drainage - CORRECT ANSWERS ✔✔Puss (assess for infection and notify
MD)
Absent Bowel Sounds - CORRECT ANSWERS ✔✔Auscultate 5 mins per quadrant
(Silence means NOTHING) (20 minute total) assess for an obstruction and notify MD
, Normal IM injection reaction - CORRECT ANSWERS ✔✔Burning at site, itching at
site, bruising
Abnormal IM injection Reaction - CORRECT ANSWERS ✔✔vomiting, constipation,
dry mouth, rash (systemic)
TB testing - CORRECT ANSWERS ✔✔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 - CORRECT ANSWERS ✔✔10mm- healthcare workers are a strict
10
TB result-positive - CORRECT ANSWERS ✔✔red, raised (induration)
Positive TB result - CORRECT ANSWERS ✔✔This means that the person has been
exposed to TB
At risk for TB - CORRECT ANSWERS ✔✔nursing homes, jails, homeless, certain
meds, some other countries, healthcare workers
Hyperglycemia - CORRECT ANSWERS ✔✔hot and dry-sugar high
Hypoglycemia - CORRECT ANSWERS ✔✔cold and clammy-needs some candy
