NUR 160-Hondros Exam 1 Study guide 2023 with complete solution

NUR 160-Hondros Exam 1 Study guide 2023 with complete solution 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