NUR 160-Hondros Exam 1 with complete solution
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, constipation, 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 result-positive
red, raised (induration)
Positive TB result
This means that the person has been exposed to TB
At risk for TB
nursing homes, jails, homeless, certain meds, some other countries, healthcare workers
Hyperglycemia
hot and dry-sugar high
Hypoglycemia
cold and clammy-needs some candy
Symptoms of Hyperglycemia
extreme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea
Symptoms of Hypoglycemia
shaking, tachycardia, sweating, anxious, dizzy, hunger, impaired vision, weakness,
fatigue, headaches, irritable
insulin
NPH-longer lasting (cloudy)
Regular- faster acting (clear)
Order of Insulin Draw
cloudy(air), clear(air),clear(insulin), cloudy(insulin)
70-110
Normal BS
Vision Intervention
Annual Eye Exam
Vision Assessment
PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark spots?,
flashes?, issues in certain lighting?)
Vision pt education
Certain drops can burn eyes, burning is better than being blind (miotics)
Hearing interventions
1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
Hearing Treatment
audiology
Cataract Assessment
1. dimness
2. misty vision
3. blurriness (milky haze)
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, constipation, 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 result-positive
red, raised (induration)
Positive TB result
This means that the person has been exposed to TB
At risk for TB
nursing homes, jails, homeless, certain meds, some other countries, healthcare workers
Hyperglycemia
hot and dry-sugar high
Hypoglycemia
cold and clammy-needs some candy
Symptoms of Hyperglycemia
extreme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea
Symptoms of Hypoglycemia
shaking, tachycardia, sweating, anxious, dizzy, hunger, impaired vision, weakness,
fatigue, headaches, irritable
insulin
NPH-longer lasting (cloudy)
Regular- faster acting (clear)
Order of Insulin Draw
cloudy(air), clear(air),clear(insulin), cloudy(insulin)
70-110
Normal BS
Vision Intervention
Annual Eye Exam
Vision Assessment
PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark spots?,
flashes?, issues in certain lighting?)
Vision pt education
Certain drops can burn eyes, burning is better than being blind (miotics)
Hearing interventions
1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
Hearing Treatment
audiology
Cataract Assessment
1. dimness
2. misty vision
3. blurriness (milky haze)
