Definitions/ A+.
just culture - Answer: workers are protected from disciplinary action when they report injuries,
errors, or near misses
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?
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, 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
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