NUR 160-Hondros Exam 1 Latest 2023 Already Passed 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 he...
NUR 160 -Hondros Exam 1 Latest 2023 Already Passed 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, co nstipation, 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 resul t-positive ✔✔red, raised (induration)
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