NUR 160-Hondros Exam 1, HONDROS NUR 160 EXAM 1, Spring hondros college Nursing 160, HONDROS NUR 160 EXAM 1, Hondros Nur160 exam 1, Nursing 160-Exam 1, Hondros- Nursing 160 exam 1 just culture - ANSWER workers are protected from disciplinary a ction when they report injuries, errors, or near misses 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 t o 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, exhal e through mouth) Order of assessmet - ANSWER Subjective then Objective (helps to identif y 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 b ad) 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 me ans 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 res ult 3. Mild swelling is normal TB result-negative - ANSWER 10mm- healthcare workers are a stri ct 10 TB result-positive - ANSWER red, raised (induration) Positive TB result - ANSWER This means that the person has been e xposed to TB At risk for TB - ANSWER nursing homes, jails, homeless, certain med s, some other countries, healthcare workers Hyperglycemia - ANSWER hot and dry-sugar high Hypoglycemia - ANSWER cold and clammy-needs some candy Symptoms of Hyperglycemia - ANSWER extreme thirst, frequent ur ination, dry skin, hunger, blurred vision, drowsiness, nausea Symptoms of Hypoglycemia - ANSWER shaking, tachycardia, sweating, anxious, d izzy, hunger, impaired vision, weakness, fatigue, headaches, irritable insulin - ANSWER NPH-longer lasting (cloudy) Regular- faster acting (clear) Order of Insulin Draw - ANSWER cloudy(air), clear(air),clear(i nsulin), cloudy(insulin) 70-110 - ANSWER Normal BS Vision Intervention - ANSWER Annual Eye Exam Vision Assessment - ANSWER PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark spots?, flashes?, issues in certain lighting?) Vision pt educatio n - ANSWER Certain drops can burn eyes, burning is better than be ing blind (miotics) Hearing interventions - ANSWER 1. Face to face 2. Speak clearly, slowly and directly 3. Eliminate background noise Hearing Treatment - ANSWER audiology Cataract Assessment - ANSWER 1. dimness 2. misty vision 3. blurriness (milky haze) Glaucoma - ANSWER High IOP Timolol - ANSWER Glaucoma Tx ARMD risks - ANSWER 1. depression 2. ignoring Sx 3. injuries, falls, accidents, mobility ARMD sight - ANSWER Loss of central vision- can see on side(may p lace things to one side or other) Glaucoma Sight - ANSWER Loss of peripheral vision-side vision Deafness Intervention - ANSWER hearing aid care Hearing aid care - ANSWER Do not wash/submerge hearing aids. T urn off when not in use, open battery door Timolol side effects - ANSWER Beta Blocker-slows heart down, w atch for SOB Malignant Tumors - ANSWER Irregular, Immobile, hard upon pa lpation, ususally not painful Important for Cancer patients - ANSWER report all new results, do not call pt and freak them out, do not just bury results in chart somewhere Smoking HX - ANSWER Smokeless tobacco? How much? How long? Cough? Would you like to quit? Pack years - ANSWER Packs per day times years, MD wants to know pa ck years Smoking prevention - ANSWER pulmonary tests, O2 levels, sputum cultu res, cessation methods, support groups, teach proper oral care Age Assessment - ANSWER physical vs. neumeric Age prevention - ANSWER sunscreen, antiaging products, lotions, hyd ration Nutrition Hx - ANSWER What do you eat? Vitamins? OTC? Restrictions? BMI- high? Low? Constipation or Diarrhea? Nutrition prevention - ANSWER Meal planning, diet, exercise, see dieti cian, if pt has cancer increase protein, low fat, increase calories Physical activity Hx - ANSWER How much? Weight bearing? Intensity? ROM problems? Pain? Aerobic or Anaerobic? Physical Activity prevention - ANSWER increased activity with plan, b uddy system, classes, pain management for exercise if needed (1 hr before)
