QUESTIONS WITH ANSWERS GRADED A+
◉ 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