NUR 231 Exam 1 Test Questions and
Correct Answers
Nursing assessment and care PACU ✅-Airway, breathing, and circulation
-Drainage Hemorrhage, tubes, lines in and out, vitals q 15 mins
-Pain control
Considerations during the nursing assessment to be used every time ✅consider the
type of surgery, wound, exposure, movement and positioning, vitals (especially <BP),
assessments (lungs, airway, heart, bleeding stability), warm, dry, comfort
What happens to the pulse and blood pressure if someone has internal bleeding?
✅pulse increases, BP decreases
Head to toe assessment techniques ✅i. Breath and heart sounds under the gown
Ii. Listen to bowels before palpation
Iii. Pedal and radial pulses
Iv. Turgor- clavicle
WBC Count ✅5,000-10,000
Hemoglobin ✅12-16
Hematocrit ✅35-50
Priority of care ✅1. Airway
2. Breathing
3. Circulation
4. Infection
5. Safety
6. Nutrition
7. Psychosocial
8. Acute vs. Chronic
9. Stable vs. Unstable
Changing patterns ✅1. How long we have patients stay
2. Foley catheters
3. Blood
4. Movement
5. Eradication of some diseases but newer ones are now a problem
6. More chronic illnesses
Medicare ✅a. Is for older people (65+) or those with permanent disability
, B. What the parts do
I. Part A: Hospital insurance
Ii. Part B: medical insurance
Iii. Part C: Medicare advantage plan
Iv. Part D: medications
Medicare Part D ✅medications
Medicaid ✅a. For the low income clients
B. Federally and state funded
C. Single moms, etc
Who sets the national patient safety goals? ✅set by QSEN and joint commisssion
What are the national patient safety goals? ✅2 patient identifiers, mark the operative
site, universal protocols, label specimen container in presence of patient, "time outs"
Staff communicatiion ✅1. Right person gets information at the right time
Med Safety ✅1. Check labels, all syringes leaving the med room are labeled. Any med
that is crushed is labeled, take time in med room, be quiet in med room
2. Be careful with high risk meds (infusions, blood thinners)
3. 9 rights
4. Check and re-check m=home meds and compare to hospital meds and times given
5. Up to date med lists.
Alarm safety ✅1. Be aware of alarm fatigue
2. Use them consistently and purposefully
Prevent infection ✅1. Primary prevention (vaccines, anti-smoking campaigns for those
who don't smoke, teaching)
2. Handwashing
3. Guidelines treating hard to treat infections (name some)
4. Reduction of infection after surgery (dressing changes, removal of Foley catheter,
turn, cough deep breathe)
5. Use proven guideline to prevent UTI and CAUTI (CHG baths, catheter removal,
sterile dressing changes, use of new methods to reduce infection in central lines)
Preventing surgical error ✅1. Time out (a last check of right patient, right treatments)
2. Label of patient (correct body part)
SBAR/ISBARQ ✅i. Situation, background, assessment, recommendation
Ii. Introduce, situation, background, assessment, recommendation, question
Iii. Pass of because of info needs to be given to keep patient safe
