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
just culture - CORRECT ANSWERS-workers are protected from disciplinary action
when they report injuries, errors, or near misses
close-ended question - CORRECT ANSWERS-What is your name?
false reassurance - CORRECT ANSWERS-Everything will be fine
Why Assess? - CORRECT ANSWERS-To identify changes in pt condition, to help
foresee areas of concern
RN - CORRECT ANSWERS-who does the initial assessment?
Within 24 hours - CORRECT ANSWERS-When should an initial assessment be done?
discharge planning - CORRECT 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 - CORRECT ANSWERS-1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - CORRECT 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 - CORRECT ANSWERS-Subjective then Objective (helps to
identify ares of focus)
,Inspect airway, auscultate lungs - CORRECT ANSWERS-If pt c/o sore throat or recent
cold
Serous Drainage - CORRECT ANSWERS-Clear(Good or indifferent)
Sanginous Drainage - CORRECT ANSWERS-Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - CORRECT ANSWERS-Pink-mix of blood and serous(This is
ok)
Purulent Drainage - CORRECT ANSWERS-Puss (assess for infection and notify MD)
Absent Bowel Sounds - CORRECT ANSWERS-Auscultate 5 mins per quadrant
(Silence means NOTHING) (20 minute total) assess for an obstruction and notify MD
Normal IM injection reaction - CORRECT ANSWERS-Burning at site, itching at site,
bruising
Abnormal IM injection Reaction - CORRECT ANSWERS-vomiting, constipation, dry
mouth, rash (systemic)
TB testing - CORRECT 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 - CORRECT ANSWERS-10mm- healthcare workers are a strict 10
TB result-positive - CORRECT ANSWERS-red, raised (induration)
Positive TB result - CORRECT ANSWERS-This means that the person has been
exposed to TB
At risk for TB - CORRECT ANSWERS-nursing homes, jails, homeless, certain meds,
some other countries, healthcare workers
Hyperglycemia - CORRECT ANSWERS-hot and dry-sugar high
Hypoglycemia - CORRECT ANSWERS-cold and clammy-needs some candy
Symptoms of Hyperglycemia - CORRECT ANSWERS-extreme thirst, frequent urination,
dry skin, hunger, blurred vision, drowsiness, nausea
Symptoms of Hypoglycemia - CORRECT ANSWERS-shaking, tachycardia, sweating,
anxious, dizzy, hunger, impaired vision, weakness, fatigue, headaches, irritable
insulin - CORRECT ANSWERS-NPH-longer lasting (cloudy)
,Regular- faster acting (clear)
Order of Insulin Draw - CORRECT ANSWERS-cloudy(air), clear(air),clear(insulin),
cloudy(insulin)
70-110 - CORRECT ANSWERS-Normal BS
Vision Intervention - CORRECT ANSWERS-Annual Eye Exam
Vision Assessment - CORRECT ANSWERS-PERRLA, peripheral testing, snellen chart,
Hx (changes in vision?, dark spots?, flashes?, issues in certain lighting?)
Vision pt education - CORRECT ANSWERS-Certain drops can burn eyes, burning is
better than being blind (miotics)
Hearing interventions - CORRECT ANSWERS-1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
Hearing Treatment - CORRECT ANSWERS-audiology
Cataract Assessment - CORRECT ANSWERS-1. dimness
2. misty vision
3. blurriness (milky haze)
Glaucoma - CORRECT ANSWERS-High IOP
Timolol - CORRECT ANSWERS-Glaucoma Tx
ARMD risks - CORRECT ANSWERS-1. depression
2. ignoring Sx
3. injuries, falls, accidents, mobility
ARMD sight - CORRECT ANSWERS-Loss of central vision- can see on side(may place
things to one side or other)
Glaucoma Sight - CORRECT ANSWERS-Loss of peripheral vision-side vision
Deafness Intervention - CORRECT ANSWERS-hearing aid care
Hearing aid care - CORRECT ANSWERS-Do not wash/submerge hearing aids. Turn off
when not in use, open battery door
Timolol side effects - CORRECT ANSWERS-Beta Blocker-slows heart down, watch for
SOB
, Malignant Tumors - CORRECT ANSWERS-Irregular, Immobile, hard upon palpation,
ususally not painful
Important for Cancer patients - CORRECT ANSWERS-report all new results, do not call
pt and freak them out, do not just bury results in chart somewhere
Smoking HX - CORRECT ANSWERS-Smokeless tobacco?
How much?
How long?
Cough?
Would you like to quit?
Pack years - CORRECT ANSWERS-Packs per day times years, MD wants to know
pack years
Smoking prevention - CORRECT ANSWERS-pulmonary tests, O2 levels, sputum
cultures, cessation methods, support groups, teach proper oral care
Age Assessment - CORRECT ANSWERS-physical vs. neumeric
Age prevention - CORRECT ANSWERS-sunscreen, antiaging products, lotions,
hydration
Nutrition Hx - CORRECT ANSWERS-What do you eat?
Vitamins? OTC?
Restrictions?
BMI- high? Low?
Constipation or Diarrhea?
Nutrition prevention - CORRECT ANSWERS-Meal planning, diet, exercise, see
dietician, if pt has cancer increase protein, low fat, increase calories
Physical activity Hx - CORRECT ANSWERS-How much?
Weight bearing?
Intensity?
ROM problems?
Pain?
Aerobic or Anaerobic?
Physical Activity prevention - CORRECT ANSWERS-increased activity with plan, buddy
system, classes, pain management for exercise if needed (1 hr before)
Carcinogen Exposure Hx - CORRECT ANSWERS-radiation (time, distance, shielding),
asbestos, led, pollution, sun or tanning, coal miner, Agent Orange?