NUR 160-Hondros Exam 1 Latest 2023 Already Passed
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
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Steps of an assessment ✔✔1. Introduce self
- Explain procedure
- wash hands
- Identify pt
- Provide privacy
- 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)
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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)
- Document date, time of injection and reading, as well as result
- Mild swelling is normal
TB result-negative ✔✔10mm- healthcare workers are a strict 10
TB result-positive ✔✔red, raised (induration)
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