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 Accurate 100%
,just culture - ANSWER workers are protected from disciplinary action 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 to 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, exhale through mouth)
Order of assessmet - ANSWER Subjective then Objective (helps to identify 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 bad)
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 means 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 result
3. Mild swelling is normal
TB result-negative - ANSWER 10mm- healthcare workers are a strict 10
TB result-positive - ANSWER red, raised (induration)
Positive TB result - ANSWER This means that the person has been exposed to TB
At risk for TB - ANSWER nursing homes, jails, homeless, certain meds, 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 urination, dry skin, hunger, blurred
vision, drowsiness, nausea
Symptoms of Hypoglycemia - ANSWER shaking, tachycardia, sweating, anxious, dizzy, 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(insulin), 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 education - ANSWER Certain drops can burn eyes, burning is better than being blind (miotics)
Hearing interventions - ANSWER 1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
Hearing Treatment - ANSWER audiology
