Hondros Nursing 160 exam 1 /100% correct answers/ revision use/2024-2025, Exams of Nursing

Download Hondros Nursing 160 exam 1 /100% correct answers/ revision use/2024-2025 and more Exams Nursing in PDF only on Docsity!

Hondros Nursing 160 exam 1 /100% correct

answers/ revision use/2024-

1.How we do Head to toe assessment?: Collect subjective and objective data 2.What is first steps of head to toe assessment?: Neurological 3.DVT (deep vein thrombosis): formation of a blood clot in a deep vein of the body, occurring most commonly in the legs or thighs 4.DVT treatment: Anticoagulants, Heparin

5. DVT prevention: - exercise, compression socks, early ambulation after surgery, smoking cessation, weight management, drug remedies, herbal remedies, monitor vitamin K intake, increase fluids and avoid alcohol 6.DVT risk factors: surgery, prior DVT, immobility, Obese, pregnancy
6. DVT signs and symptoms: Unilateral leg swelling, pain or tenderness, skin discoloration (redness), Palpation of cord-like obstruction over vein, 8.What is the main purpose of insulin?: control blood sugar level in your body
7. Diabetes mellitus type 1: A chronic condition in which the pancreas

produces little or no insulin, Usually occurs in childhood and adolescents, Insulin-dependent to maintain blood sugar level 10.Diabetes mellitus type 2: More common in adults, The pancreas makes unhealthy insulin 11.Treatment for diabetes mellitus type 2: Dietary intervention, exercise, oral medication, and insulin (possible) 12.gestational diabetes: Diabetes that develops during pregnancy, Can be very dangerous to both child and mother 13.Insulin measure?: Units 14.Insulin drawing?: Cloudy, clear, clear, cloudy 15.Regular insulin: Short acting insulin (clear) 16.NPH insulin: Long acting insulin (Cloudy) 17.Important when using insulin?: Make sure patient is always rotating sites, SubQ 18.What are insulin sites?: Abdomen (common sites), upper arms, thighs (simple

• for self-injection), lower back, hips, or buttocks 19.When patient is newly diagnosed of diabetes?: Educate them about diet control, Regular exercise, Teach them to take blood sugar test on their own 20.When Checking for blood sugar?: Rotate fingers, In stable adults, lateral side of the finger, Position patient comfortable in a chair or semi-fowlers position 21.What is the best way to prevent infection?: Hand wash (15-30) seconds, PPE 22.Cardinal signs and symptoms of infection: Fever, low white blood cells count, Inflammation, changes in LOC or mental status, Redness, Swelling in any area, chills and sweats 23.Cataracts: Clouding of the lens 24.Symptoms of cataracts: Blurred-hazy vision, halo around lights, Yellow, white, or gray discoloration of pupil, gradual loss of vision. 25.Cataracts - Treatment and management: Surgery 26.Risk fact for cataracts: Diabetes mellitus, smoking,

27.Safety issue for cataract: They could fall, no driving, no physical maneuverabil- ity 28.Patient education for cataracts: - Do not rub the eyes or press on them

• Do not lie on the operative side for a few days
• Wear bandage
• They should not be left alone after surgery 29.How do we irrigate wound?: - Make sure the solution flows from the clean tissue to dirty area of the wound to prevent contamination
• Avoid cleansing wounds with cytotoxic solution
• Be sure solution reaches all areas of the wound
• Use bath blanket/waterproof 30.How do we do wet to dry dressing?: - Patient position comfortable
• Drape patient to expose only the wound site
• Instruct patient not to touch wound or sterile supplies
• Damp the gauze, placed on the wound, apply a dry, sterile gauze pad over the wet gauze 31.1. Purpose of wet to dry dressing?: To keep the wound bed moist

and to provide mechanical debridement 32.Wound dressing: The layer of a bandage that contacts and protects the wound, the primary layer 33.Three types of surgery: - Elective: is for medical reason (mastectomy for breast cancer, orthopedic surgeries)

• Urgent: is usually done within two days (Gall bladder removal, appendectomy)
• Emergent: is when patient's condition is life-threatening (preserve a limb, bodily function) 34.What happens if a patient is unresponsive, therefor unable to consent to surgery and there is no family member present to give consent for surgery?: - Still go through the surgery
• Informed/implied consent is presumed for patient 35.Maintain ulcers: - Rotate patient position (bed - 2 hours, wheelchair - 1 hour)
• Put the pillow and avoid from touching other body parts
• Manage moisture 36.Just culture: Filling out the incident report without fear of termination

37.What the incident report does?: Teach us about what went wrong during care 38.Diagnostic error: Failure to detect an actual unhealthy behavior or condition 39.Treatment error: occur in the performance of an operation, procedure, or test; in administering a treatment; in the dose or method of administering a drug; or in avoidable delay in treatment or in responding to an abnormal test 40.Preventive errors: occur when there are failures to provide prophylactic treat- ment and inadequate monitoring or follow-up of treatment. 41.Communication errors: Failure to communicate 42.Active errors: Errors made during care provided 43.Latent error: condition involves problems within the system; may lie dormant within the system for a long time; pose the greatest threat to safety in a complex system 44.Assessing the abdomen: Inspection, auscultation, palpation 45.Narcotics: - Hydrocodone, Percocet, Morphine, Vicodin

• Binds to opioid receptors in the brain to decrease pain
• Schedule 2
• Side effects - drowsiness, dizzy, anxiety, itching 46.Assessment before/after of patient using Narcotics: Vital signs, PQRST 47.Why do we do vital signs of a patient taking pain medication?: To know if the patient has respiratory depression, incoherent, drowsiness, dizzy 48.What drug do we choose for severe pain?: Morphine 49.Can morphine and Tylenol be given together?: YES 50.Acetaminophen: For mild pain, Side effects - Jaundice, dark urine, nausea, hepatic 51.Tylenol: Acetaminophen, Reduces fever, minor aches, pain, schedule 3 52.Percocet: Oxycodone/acetaminophen, schedule 2 53.Black box warning: A notice that a drug may produce serious or even life-threat- ening effects in some people in addition to its beneficial effects. 54.Major morphine (opioids) effects?: Respiratory depression (can be

fatal) 55.Why do we use opioids?: Acute pain - surgery Chronic pain - cancer 56.Opiates side effects: Drowsiness, sedation, dizziness, lethargy Nausea, vomiting, anorexia, constipation Respiratory depression

Bradycardia, palpitations, hypotension Urinary retention Flushing, rash, urticaria 57.How do you monitor patient that takes opioids?: Pain assessment, Observe respiratory rate 58.Half-life: The amount of times it takes for 50% elimination from body 59.Reglan: Empty's the stomach, Treat nausea and vomiting 60.Why would Reglan nbe given prior to surgery?: To manage nausea and vomiting 61.Maximum Dosage for Acetaminophen: 4 g or 4000 mg 62.Ask about allergies: What type of reaction are you having? 63.If a patient is immobile post-operatively what are they risk for?: DVT (Deep Venous Thrombosis) 64.Which assessment finding is objective?: Purulent drainage - you can mea- sure this 65.The nurse is assessing a post-operative patient which of the

following should nurse document as subjective data?: Pain - subjective data 66.A patient with Glaucoma would likely to have which of the following IOP (Intraocular pressure) readings?: 48 mmHg or high than normal range due to high pressure in the eyes (Normal range 10 - 22 mmHg) 67.Glaucoma: Increased intraocular pressure, Loss in peripheral vision 68.Treatment of Glaucoma: Timolol - beta blocker to reduce IOP (Side effects of timolol - slow down heart rate, shortness of breath) 69.Teach glaucoma patient: Glaucoma medication may cause burning, but it is better than being blind 70.Putting sunscreen, getting flu vaccines is an example of which type of prevention?: Primary prevention 71.Secondary prevention: Screening and early detection 72.Tertiary prevention: Prevention of complications from an existing disease and promoting health to the highest level 73.Which of the following foods should a patient with leukemia

avoid?: Carrot sticks, fresh fruits/vegetables, raw meat, fish 74.Why do we do initial vitals?: For comparison 75.What are the disadvantages of morphine use?: Addiction, potential for drug dependency 76.Patient with Small Bowel Obstruction (SBO), what odors would you expect from the physician?: - Maintain high-fowler's position

• Palpate abdomen every 2 hours
• Insert NG tube but leave clamped 77.What is the most important intervention in a patient with visual impair- ment?: Keep clear walkaways - most important safety issue 78.True statement about the culture?: Culture needs to be considered in a patient care 79.What is a normal side effect of Latanoprost eye drops?: Burning 80.Analgesics (Medications): Pain relievers 81. What assessment finding indicated a post-operative wound infection?: - Foul odor, redness, swelling, color, purulent drainage

82.Range of Motion (ROM): keep joint mobile, blood circulating, good for pneumo- nia 83.Examples of open-ended questions: - Tell me how you are feeling

• Tell me how your health has been
• Describe how your wife has been helping you
• Give me an example of how you get relief from your pain at home 84.Examples of close-ended questions: Are you in pain? Can you tell me your name? 85.How do we assess patient neurological status?: Ask their name, place, location, use assessment tools 86.When we have a patient receiving chemo, what do their WBC look like?: - Low white blood cells count
• Use neutropenic precaution 87.Neutropenic precautions (low WBC): Strict handwashing, avoid crowds, pri- vate room, low bacteria diet (no raw or undercooked), avoid fresh flowers, plants, fruits 88.What pulse can be done at the same time?: All pulse, except carotid (emer- gency only)

89.Warfarin (Coumadin) Blood thinners: - Used to treat blood clots, DVT

• PT (11-14 seconds), INR (2-3 in normal patient) 90.Anticoagulants (blood thinners): Substances that prevent blood clotting 91.Anticoagulants safety precautions: - Do not mix with Aspirin, Plavix
• Do not use electric razor
• When their PTINR is high - take vitamin K 92.When do you take Coumadin?: After dinner, always at same time 93.If they are fall risks?: Use their assistive devices 94.How do we measure fall risks?: Using morse fall scale 95.Risk factors for patient going to the surgery: - Low white blood cells count (high risk for infection)
• Infection
• Diabetes, coronary disease
• HIV, hypertensive 96.Communicating someone from other cultures to consider: - Their beliefs, maintain eye contact, household beliefs, certain time a day that they need to be alone, language barriers (medical expert translator)

97.Patient with COPD (Chronic obstructive pulmonary disease) position: High fowlers 98.Ventilation patient position: Semi-fowlers 99.Position receiving J tube, G tube: Semi - high fowler

100. Glasgow coma scale measure? What do we Assess?: How responsive patient is? Do they open their eyes, responsive, follow direction, give them points?

• Lower the score - unresponsive

101. Eviscerate: When organ is out

• normal saline - emergent situation, call doctors

102. Dehiscence: Bursting open of a wound, especially a surgical abdominal wound, Cover up the wound, call the doctors
103. Factors that effects wound healing: Smoking, diabetes, malnutrition
104. If we discover that patient has allergies to anything: Ask them what type of reaction they have? health history, allergy band, document

105. Math

• when doctors order 500mg every 4 hours. (acetaminophen) 4 gram and 4000 mg do not exceed: - 500 mg every 4 hours (500 x 6 = 3000 mg) under the dosage (can give)
• If doctor order more than 1000 mg every 4 hours (1000 x 6 = 6000 mg) over the maximum dose (contact doctors) 106. #Amoxicillin 500 mg every 3 times a day. Only have 250 mg in the store: - 500/250 = 2 tabs/dosage x 3 = 6 tab/dose/day

107. Hair remover for surgery?: Clippers only
108. Malignant tumor (can be fatal): Immovable, metastasis, rapidly growing, heart irregular
109. Benign tumor (it is not fatal): Moveable, does not invade surrounding tissue
110. Longer to clot due to: Increased bleeding
111. What prevents clotting after surgery?: Circulation, leg exercises, anticoag- ulant

112. Apical pulse location: Mid clavicular line, 5th intercostal space
113. Prick the finger: (Blood sugar testing) Scrub with alcohol, prick, wipe of first blood, with gauze take second blood for testing
114. Hemo-Vac Drain: Drain fluids that builds up after surgery
115. wound vac: Uses negative pressure to support healing
116. Jackson-Pratt drain: Hollow bulb-like device used to collect drainage, bodily fluids from surgical sites
117. Most common cancer in women: Lung cancer
118. Most common cancer in men: Prostate cancer
119. Absent Bowel sounds: - Constipation

• Assess for an obstruction 5 mins per each quadrant, Notify MD

120. Living will: A document in which a person states his or her wishes about life support and other treatments
121. Power of attorney: A legal document authorizing someone to act on your behalf
122. How long wound care saline is good for?: 24 hours
123. SSI (sliding scale insulin): Give based on the blood glucose level (AC, HS)

124. Latex allergy: - Must use latex-free gloves
125. Good communication skills: To know how to socialize with people
126. Risk factor of cancer: Alcohol, smoking, obesity, genetics
127. Oral Medications: Administered PO, can be solid or liquid (tablets, capsules, caplets).
128. Blocks to communication: False reassurance Giving advice False assumptions Defensiveness Arguing Asking for explanations Changing the subject
129. Why assess?: To identity any changes in their health conditions (help foresee concerns)

130. Who does the initial assessment?: Rn
131. When the initial assessment should be done?: Within 24 hours
132. First Steps in Assessment: Introduce yourself
133. What do you do if concern rises during an assessment?: You correct it and then continue
134. What is the order of an assessment?: Subjective, Objective
135. What do you do if a patient complains of sore throat or recent cold?: In- spect airways, auscultate lungs
136. Example of false reassurance: Everything will be fine
137. Important for cancer patient: Report all new result, do not call and freak out the patient
138. Chemotherapy side effects: 1. bone marrow suppression 2.nausea and vomiting 3.altered immunologic response 4.impaired oral mucous membrane 5.stomatitis 6.fatigue

139. Hormonotherapy side effects: DVT risk with estrogen
140. When you begin pre-op patient education?: As soon as the patient knows about the surgery
141. To teach pre-op instruction: Patient mush have motivation to learn
142. GI Prep: -NPO at midnight before surgery (decreases chance of vomiting or aspirating emesis after surgery)
143. incentive spirometer: 10x per hour
144. Cancer secondary prevention: Identification of patients at high cancer risk Cancer screening

• Self-breast exam
• Self-testicular exam
• Screening colonoscopy
• Pap smear Public, patient education

145. ARMD (age related macular degeneration): degenerative eye

disease that affects the macula that causes a progressive decrease in central vision, leaving only peripheral vision

146. Risk factors of ARMD: Family history, long exposure to UV light, smoking, female, obesity, white, light colored eyes
147. Vision Interventions: Annual exam Use contrast Reduce glare Large print Magnifiers Utilize other senses Clean glasses
148. Deafness Intervention: Hearing aid care
149. What do you do if patient thinks meds are wrong?: Check again
150. What do if patient vomits right after medication administration?: Call doctor

151. Why NPO?: To decrease the risk for aspiration.
152. Medical Terminology: The use of prefixes, suffixes, word roots, and combining forms to construct anatomical, physiological, or medical terms. 1.Onset - when the drug will start working, 2.Peak - when the drug reaches its higher concentration, 3.Duration - how long the drug lasts (half-life), 4.Drug level - amount of drug present
153. Physical Assessment: Systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems
154. What is risk associated with impaired vision?: Falls
155. Vision assessment: PERRLA, peripheral testing, snellen chart, Hx (changes in vision?, dark spots?, flashes?, issues in certain lighting?)
156. How do we diagnose hearing deficits?: Audiometric testing
157. Hearing interventions: 1. Face to face

2.Speak clearly, slowly and directly 3.Eliminate background noise

158. Hearing Treatment: Audiology
159. Caring for hearing aid: Do not immerse in water, Turn off battery when not in use
160. Who is responsible for is it to keep track of the hearing aids?: Nurses
161. Serous drainage: Clear, watery plasma
162. Sanguineous drainage: Bright red; indicates active bleeding (bloody drainage)
163. Serosanguineous drainage: Pale, red, watery: mixture of serous and san- guineous
164. Purulent drainage: Thick green, yellow, or brown drainage 'Pus'
165. Cancer stages: 0-4, 0 is in situ, 1 localized,

2 limited spread, 3 regional spread, 4 metastasis

166. What should we pay attention to when a pt is post op knee replacement and they live on 2nd floor?: Discharge planning
167. Populations at risk for surgical complications: Young and the very old, nutritional needs, chronic disease, people under stress (fear or anxiety), certain cultures, people on multiple medications and herbal remedies
168. Immunodeficiency: Failure of the immune system, Slow healing, Prone to infection
169. Pre-op testing: Glucose level, EKG, blood counts, liver and kidney function, serum electrolytes, blood chem profile. Does the patient have any chronic condi- tions?
170. Concerns for education: Level of cognition, How does the person learn?
171. Skin Prep for surgery: 1. When and how to cleanse skin and with

what 2.If shaving is ordered, when, how, where 3.What not to use on cleansed skin

172. Respiratory prep for surgery: 1. How to use incentive spirometer 2.What sputum should and should not look like 3.Why incentive spirometer is important, what symptoms do they need to report
173. Cardiovascular consideration for surgery: Need for practicing leg exercises
174. Urinary Considerations for surgery: 1. Encourage fluid intake 2.Voiding when needed 3.Complications from urinary retention
175. Pain control for surgery: 1. Safe and effective relief 2.Staying ahead of pain 3.Being careful while medicated
176. Preoperative med concerns: 1. What to take morning of 2.What to hold and for how long 3.Why

177. Wrong site, Wrong Procedure, and Wrong Person Surgery Protocol: Ask patient who they are, DOB, what they are having done Check this against orders ID bracelet
178. Infection: invasion of the body by a pathogenic organism
179. NG tube placement: Xay to confirm proper placement
180. NG tube feeding process: Check placement, residual, flush, give/feed, flush
181. Reasons for physical assessment: To get a baseline, check for issues/prob- lems, check for fall risk on admission, helps create nursing interventions, LPN helps create care plan by taking data
182. SSI (surgical site infection): An infection of the surgical wound that was acquired during the course of the surgical procedure