HONDROS NUR 160 EXAM with
answers verified
just culture - ANS✅✅workers are protected from disciplinary action when they report injuries,
errors, or near misses
close-ended question - ANS✅✅What is your name?
false reassurance - ANS✅✅Everything will be fine
Why Assess? - ANS✅✅To identify changes in pt condition, to help foresee areas of concern
RN - ANS✅✅who does the initial assessment?
Within 24 hours - ANS✅✅When should an initial assessment be done?
discharge planning - ANS✅✅What should we pay attention to when a pt is post op knee
replacement and they live on 2nd floor
Steps of an assessment - ANS✅✅1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - ANS✅✅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 - ANS✅✅Subjective then Objective (helps to identify ares of focus)
,Inspect airway, auscultate lungs - ANS✅✅If pt c/o sore throat or recent cold
Serous Drainage - ANS✅✅Clear(Good or indifferent)
Sanginous Drainage - ANS✅✅Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - ANS✅✅Pink-mix of blood and serous(This is ok)
Purulent Drainage - ANS✅✅Puss (assess for infection and notify MD)
Absent Bowel Sounds - ANS✅✅Auscultate 5 mins per quadrant (Silence means NOTHING) (20
minute total) assess for an obstruction and notify MD
Normal IM injection reaction - ANS✅✅Burning at site, itching at site, bruising
Abnormal IM injection Reaction - ANS✅✅vomiting, constipation, dry mouth, rash (systemic)
TB testing - ANS✅✅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 - ANS✅✅10mm- healthcare workers are a strict 10
TB result-positive - ANS✅✅red, raised (induration)
Positive TB result - ANS✅✅This means that the person has been exposed to TB
At risk for TB - ANS✅✅nursing homes, jails, homeless, certain meds, some other countries,
healthcare workers
Hyperglycemia - ANS✅✅hot and dry-sugar high
,Hypoglycemia - ANS✅✅cold and clammy-needs some candy
Symptoms of Hyperglycemia - ANS✅✅extreme thirst, frequent urination, dry skin, hunger, blurred
vision, drowsiness, nausea
Symptoms of Hypoglycemia - ANS✅✅shaking, tachycardia, sweating, anxious, dizzy, hunger,
impaired vision, weakness, fatigue, headaches, irritable
insulin - ANS✅✅NPH-longer lasting (cloudy)
Regular- faster acting (clear)
Order of Insulin Draw - ANS✅✅cloudy(air), clear(air),clear(insulin), cloudy(insulin)
70-110 - ANS✅✅Normal BS
Vision Intervention - ANS✅✅Annual Eye Exam
Vision Assessment - ANS✅✅PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark
spots?, flashes?, issues in certain lighting?)
Vision pt education - ANS✅✅Certain drops can burn eyes, burning is better than being blind
(miotics)
Hearing interventions - ANS✅✅1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
Hearing Treatment - ANS✅✅audiology
Cataract Assessment - ANS✅✅1. dimness
2. misty vision
, 3. blurriness (milky haze)
Glaucoma - ANS✅✅High IOP
Timolol - ANS✅✅Glaucoma Tx
ARMD risks - ANS✅✅1. depression
2. ignoring Sx
3. injuries, falls, accidents, mobility
ARMD sight - ANS✅✅Loss of central vision- can see on side(may place things to one side or other)
Glaucoma Sight - ANS✅✅Loss of peripheral vision-side vision
Deafness Intervention - ANS✅✅hearing aid care
Hearing aid care - ANS✅✅Do not wash/submerge hearing aids. Turn off when not in use, open
battery door
Timolol side effects - ANS✅✅Beta Blocker-slows heart down, watch for SOB
Malignant Tumors - ANS✅✅Irregular, Immobile, hard upon palpation, ususally not painful
Important for Cancer patients - ANS✅✅report all new results, do not call pt and freak them out,
do not just bury results in chart somewhere
Smoking HX - ANS✅✅Smokeless tobacco?
How much?
How long?
Cough?
Would you like to quit?
answers verified
just culture - ANS✅✅workers are protected from disciplinary action when they report injuries,
errors, or near misses
close-ended question - ANS✅✅What is your name?
false reassurance - ANS✅✅Everything will be fine
Why Assess? - ANS✅✅To identify changes in pt condition, to help foresee areas of concern
RN - ANS✅✅who does the initial assessment?
Within 24 hours - ANS✅✅When should an initial assessment be done?
discharge planning - ANS✅✅What should we pay attention to when a pt is post op knee
replacement and they live on 2nd floor
Steps of an assessment - ANS✅✅1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
Correct, then continue - ANS✅✅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 - ANS✅✅Subjective then Objective (helps to identify ares of focus)
,Inspect airway, auscultate lungs - ANS✅✅If pt c/o sore throat or recent cold
Serous Drainage - ANS✅✅Clear(Good or indifferent)
Sanginous Drainage - ANS✅✅Blood-red(a little is ok, alot is bad)
Serosanginous Drainage - ANS✅✅Pink-mix of blood and serous(This is ok)
Purulent Drainage - ANS✅✅Puss (assess for infection and notify MD)
Absent Bowel Sounds - ANS✅✅Auscultate 5 mins per quadrant (Silence means NOTHING) (20
minute total) assess for an obstruction and notify MD
Normal IM injection reaction - ANS✅✅Burning at site, itching at site, bruising
Abnormal IM injection Reaction - ANS✅✅vomiting, constipation, dry mouth, rash (systemic)
TB testing - ANS✅✅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 - ANS✅✅10mm- healthcare workers are a strict 10
TB result-positive - ANS✅✅red, raised (induration)
Positive TB result - ANS✅✅This means that the person has been exposed to TB
At risk for TB - ANS✅✅nursing homes, jails, homeless, certain meds, some other countries,
healthcare workers
Hyperglycemia - ANS✅✅hot and dry-sugar high
,Hypoglycemia - ANS✅✅cold and clammy-needs some candy
Symptoms of Hyperglycemia - ANS✅✅extreme thirst, frequent urination, dry skin, hunger, blurred
vision, drowsiness, nausea
Symptoms of Hypoglycemia - ANS✅✅shaking, tachycardia, sweating, anxious, dizzy, hunger,
impaired vision, weakness, fatigue, headaches, irritable
insulin - ANS✅✅NPH-longer lasting (cloudy)
Regular- faster acting (clear)
Order of Insulin Draw - ANS✅✅cloudy(air), clear(air),clear(insulin), cloudy(insulin)
70-110 - ANS✅✅Normal BS
Vision Intervention - ANS✅✅Annual Eye Exam
Vision Assessment - ANS✅✅PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark
spots?, flashes?, issues in certain lighting?)
Vision pt education - ANS✅✅Certain drops can burn eyes, burning is better than being blind
(miotics)
Hearing interventions - ANS✅✅1. Face to face
2. Speak clearly, slowly and directly
3. Eliminate background noise
Hearing Treatment - ANS✅✅audiology
Cataract Assessment - ANS✅✅1. dimness
2. misty vision
, 3. blurriness (milky haze)
Glaucoma - ANS✅✅High IOP
Timolol - ANS✅✅Glaucoma Tx
ARMD risks - ANS✅✅1. depression
2. ignoring Sx
3. injuries, falls, accidents, mobility
ARMD sight - ANS✅✅Loss of central vision- can see on side(may place things to one side or other)
Glaucoma Sight - ANS✅✅Loss of peripheral vision-side vision
Deafness Intervention - ANS✅✅hearing aid care
Hearing aid care - ANS✅✅Do not wash/submerge hearing aids. Turn off when not in use, open
battery door
Timolol side effects - ANS✅✅Beta Blocker-slows heart down, watch for SOB
Malignant Tumors - ANS✅✅Irregular, Immobile, hard upon palpation, ususally not painful
Important for Cancer patients - ANS✅✅report all new results, do not call pt and freak them out,
do not just bury results in chart somewhere
Smoking HX - ANS✅✅Smokeless tobacco?
How much?
How long?
Cough?
Would you like to quit?
