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NUR 160-HONDROS EXAM 1 QUESTIONS AND ANSWERS
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NUR 160-HONDROS EXAM 1 QUESTIONS AND ANSWERS
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NUR 160-HONDROS EXAM 1 QUESTIONS ANDANSWERS
just culture - Answers-workers are protected from disciplinary action when they report
injuries, errors, or near misses
close-ended question - Answers-What is your name?
false reassurance - Answers-Everything will be fine
Why Assess? - Answers-To identify changes in pt condition, to help foresee areas of
concern
RN - Answers-who does the initial assessment?
Within 24 hours - Answers-When should an initial assessment be done?
discharge planning - 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 - Answers-1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - 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 - Answers-Subjective then Objective (helps to identify ares of focus)
Inspect airway, auscultate lungs - Answers-If pt c/o sore throat or recent cold
Serous Drainage - Answers-Clear(Good or indifferent)
Sanginous Drainage - Answers-Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - Answers-Pink-mix of blood and serous(This is ok)
Purulent Drainage - Answers-Puss (assess for infection and notify MD)
, Absent Bowel Sounds - Answers-Auscultate 5 mins per quadrant (Silence means
NOTHING) (20 minute total) assess for an obstruction and notify MD
Normal IM injection reaction - Answers-Burning at site, itching at site, bruising
Abnormal IM injection Reaction - Answers-vomiting, constipation, dry mouth, rash
(systemic)
TB testing - 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 - Answers-10mm- healthcare workers are a strict 10
TB result-positive - Answers-red, raised (induration)
Positive TB result - Answers-This means that the person has been exposed to TB
At risk for TB - Answers-nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
Hyperglycemia - Answers-hot and dry-sugar high
Hypoglycemia - Answers-cold and clammy-needs some candy
Symptoms of Hyperglycemia - Answers-extreme thirst, frequent urination, dry skin,
hunger, blurred vision, drowsiness, nausea
Symptoms of Hypoglycemia - Answers-shaking, tachycardia, sweating, anxious, dizzy,
hunger, impaired vision, weakness, fatigue, headaches, irritable
insulin - Answers-NPH-longer lasting (cloudy)
Regular- faster acting (clear)
Order of Insulin Draw - Answers-cloudy(air), clear(air),clear(insulin), cloudy(insulin)
70-110 - Answers-Normal BS
Vision Intervention - Answers-Annual Eye Exam
Vision Assessment - Answers-PERRLA, peripheral testing, snellen chart, Hx (changes
in vision?, dark spots?, flashes?, issues in certain lighting?)
Vision pt education - Answers-Certain drops can burn eyes, burning is better than being
blind (miotics)
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