Exam 3 Study Guide: Quizlet

Question 1

the nurse is performing a respiratory assessment and detects a low pitch, sot sound. The inspiratory phase is longer than expiration. The nurse interprets this as?

Answer 1

vesicular sound

Question 2

when percussing the chest, what sound would the nurse expect to hear over the lungs?

Answer 2

resonance

Question 3

the nurse auscultates an extra sound over the left lower lobe. The nurse should: document finding,

Answer 3

Ask client to cough

Question 4

upon auscultation the nurse detects an extra gurgling, expiratory sound in the upper airways. the nurse interprets this as?

Answer 4

rhonchi

Question 5

inspection of the chest includes assessing the anterior-posterior: lateral ratio. the normal finding for an adult is:

Answer 5

1:2

Question 6

the nurse is performing a cardiac assessment. Which site is best for palpating the PMI?

Answer 6

apex

Question 7

the nurse detects a trill while palpating the carotids. what sound would the nurse expect to hear when auscultating the carotids?

Answer 7

bruit

Question 8

how would the nurse differentiate carotid from venous pulsations?

Answer 8

jugulars affected by breathing

Question 9

during cardiac auscultation, the nurse detects a low pitch early diastolic sound at the apex. the nurse interprets this as:

Answer 9

S3

Question 10

there are many different causes of chest pain. Which area should be addressed first when a client presents with chest pain?

Answer 10

cardiac

Question 11

where are bronchovesicular sounds heard?

Answer 11

over major bronchi near sternal notch

Question 12

where are bronchial sounds heard?

Answer 12

over trachea or larynx, up by clavicle

Question 13

where are vesicular sounds heard?

Answer 13

over peripheral lung fields - mostly what we listen to

Question 14

Causes, sounds, and associated conditions of Rales/Crackles?

Answer 14

caused by air passing through fluid

sounds like bubbling/crackling like rice crispy
soft, high-pitched, very brief
usually on inspiration

pulmonary edema
atelectasis
fibrosis
pneumonia

Question 15

causes, sounds, and associated conditions of wheezes?

Answer 15

narrowing of airway passages

can be heard on inspiration or expiration

asthma
COPD

Question 16

cause, sounds, and associated conditions of rhonchi?

Answer 16

mucous secretions in large airway

coarse, snoring, low-pitched, continuous sounds
usually on expiration but can be on inspiration as well

might snore from mucous build up
may clear with coughing

pneumonia
bronchitis
emphysema

Question 17

cause, sounds, and associated conditions of friction rub?

Answer 17

inflammation in pleural spaces

high-pitched grating or rubbing sound

best heard over lower lateral lungs

infection/inflammation of pleura - pleuritis

Question 18

cause, sounds, and associated conditions of stridor?

Answer 18

medical emergency - partial airway obstruction
child swallowed object, laryngeal spasms, or epiglottitis

high-pitched continuous honking sound

prominent on inspiration

Question 19

cause, sounds, and associated conditions of grunting

Answer 19

retention of air in the lungs

high-pitched tubular sound
heard on expiration

emphysema - unable to fully exhale

Question 20

what is the pathway of the electrical impulse through the heart?

Answer 20

starts in the right atria at the SA node

across the internodal pathways to left atria

AV node then bundle of his where there is a short pause

down right and left bundle branches to purkinje fibers which contract the ventricles

Question 21

what is the pathway of blood through the heart?

Answer 21

superior and inferior vena cava
right atrium
tricuspid valve
right ventricle
pulmonary valve
pulmonary artery
lungs
pulmonary vein
left atrium
mitral valve
left ventricle
aorta
body

Question 22

what are symptoms of left-sided heart failure?

Answer 22

blood backs up into the lungs

pulmonary congestion
cough
blood-tinged sputum
tacypnea
tachycardia
restless
confusion
dyspnea - worse with exertion
cyanosis - check MM/sclera in patient with darker skin tone
fatigue
lung sounds: crackles and wheezes

Question 23

what are the symptoms of right-sided heart failure?

Answer 23

blood backs up coronary vein

fatigue
increased JVD
ascites
hepatosplenomegaly
anorexia
weight gain
edema

Question 24

what are modifiable risk factors for hypertension?

Answer 24

alcohol intake
smoking
stress
obesity
stress
diet
lack of exercise

Question 25

what are non-modifiable risk factors for hypertension?

Answer 25

family hx age 65 and older

Question 26

what are symptoms of peripheral artery disease?

Answer 26

hair loss on lower limbs weak or absent peripheral pulses ulcerations in toes and lower limbs that do not bleed pain with walking legs cool to the touch

Question 27

what are symptoms of peripheral venous disease?

Answer 27

develop wounds that usually have drainage skin gets very thick and brown

Question 28

how many lobes are in each lung?

Answer 28

right = 3 left = 2

Question 29

what is the order of techniques for the respiratory assessment?

Answer 29

inspection, palpation, percussion, auscultation

Question 30

lining of the lungs

Answer 30

pleura

Question 31

major airway passages of the lungs

Answer 31

bronchi

Question 32

smaller airway passages of the lungs

Answer 32

bronchioles

Question 33

location of gas exchange

Answer 33

alveoli

Question 34

where can you check for cyanosis?

Answer 34

conjuctiva oral mucous membranes anywhere without heavy pigmentation

Question 35

what lung changes occur in an older adult?

Answer 35

loss of tissue elasticity increased rigidity difficult to inflate increased risk for pneumonia

Question 36

what is the benefit of increased hydration to a pneumonia patient?

Answer 36

thin secretions

Question 37

who is at increased risk for pneumonia?

Answer 37

COPD patients older adults

Question 38

what are typical subjective and inspection findings for COPD patient?

Answer 38

subjective: dyspnea chronic productive cough fatigue inspection: tachypnea productive cough clubbing increased AP diameter accessory muscle use short shallow breaths prolonged expiration O2 sat levels low 88-89% or even lower

Question 39

what are typical percussion and auscultation findings for a COPD patient?

Answer 39

percussion: decreased diaphragmatic excursion hyperresonance due to trapped air auscultation: decreased breath sounds possible occasional wheeze and crackles

Question 40

what is a side effect of opioids?

Answer 40

CNS depression - bradypnea shallow respirations

Question 41

what is normal RR?

Answer 41

12 - 20 bpm

Question 42

what is bradypnea RR?

Answer 42

< 12 bpm

Question 43

what is tachypnea RR?

Answer 43

> 20 bpm

Question 44

what are ways to prevent respiratory complications post op?

Answer 44

encourage inspiratory spirometer (IS) every hour while awake brush teeth BID encourage the client to cough and deep breath sit in chair for each meal

Question 45

what is the order of techniques for cardiovascular assessment?

Answer 45

inspection, palpation, auscultation (no percussion)

Question 46

what do you need to do if the radial pulse is irregular?

Answer 46

auscultate the apical pulse for a full minute

Question 47

what is a pulse deficit?

Answer 47

difference between the radial and apical pulse

Question 48

what do each of the pulse scores mean?

Answer 48

0 = absent pulse 1+ = weak, diminished, thready 2+ = normal, brisk 3+ = full 4+ = bounding

Question 49

in the absence of disease, how do you characterize peripheral pulses?

Answer 49

symmetrical strength quality quantity

Question 50

how does systolic BP, CO, and arterial walls change with age?

Answer 50

systolic BP: increases CO: decreases arterial walls: thicken

Question 51

what is the meaning of systolic blood pressures?

Answer 51

how much pressure is exerted against artery walls during ventricular contraction

Question 52

what is the meaning of diastolic blood pressures?

Answer 52

how much pressure is exerted against artery walls while the heart is resting between beats

Question 53

what is the criteria and symptoms orthostatic hypotension?

Answer 53

drop in blood pressure >20 systolic with position changes dizziness, weakness, and fainting

Question 54

what position and tools are required to assess for JVD?

Answer 54

elevate patients head to 45 degrees or semi-fowlers use a penlight

Question 55

what is occurring during S1 heart sounds?

Answer 55

S1 = lub AV valve (mitral and tricuspid) closure

Question 56

what is occurring during S2 heart sounds?

Answer 56

S2 = dub aortic and pulmonic valve closure and marks the beginning of diastole

Question 57

what causes a swishing sound during cardiovascular auscultation?

Answer 57

murmurs - could indicate the presence of heart disease and valve malfunction

Question 58

what 4 peripheral pulses can be palpated in the lower extremities?

Answer 58

femoral pulse popliteal pulse posterior tibial dorsalis pedis

Question 59

what symptoms would have higher priority than chest pain?

Answer 59

airway and breathing - ex dyspnea chest pain abnormal cardiovascular finding and related to curculation

Question 60

what is a barreled chest and what disease is associated with this finding?

Answer 60

altered shape 1:1 length to width ratio COPD chronically overinflated lungs so rib cage remains partially expanded

Question 61

what are normal percussion findings during respiratory assessment?

Answer 61

anterior chest: resonance to 2nd ICS on left to 4th ICS on right

Question 62

what are abnormal percussion findings during respiratory assessment?

Answer 62

dullness: tumors fluid pleural effusion pneumonia pulmonary edema

Question 63

what changes occur with an older client's blood pressure?

Answer 63

increased systolic

Question 64

which patient should you see first: one with hypertension one who is leaving for surgery or one who has chest pain?

Answer 64

chest pain

Question 65

which can AP perform for you: palpate pedal pulses performed health history put a patient on oxygen or document intake/output?

Answer 65

document intake/output

Question 66

when auscultating the heart and listening for high pitched sounds, what part of the stethoscope do you use?

Answer 66

diaphragm

Question 67

if you gave a client medications then come back in 30 min to see how they are, what part of nursing process is this?

Answer 67

evaluation

Question 68

when BP drops with positional changes, what is that called and what nursing diagnosis can be used?

Answer 68

orthostatic hypotension risk for falls risk for injury

Question 69

what is occurring during lub heart sound?

Answer 69

AV valve closure

Question 70

what occurs during dub heart sound?

Answer 70

aortic and pulmonic valves closing

Question 71

bubbling popping rattling lung sounds are called?

Answer 71

crackles

Question 72

high pitched musical squeaking lung sound are called?

Answer 72

wheezes

Question 73

how do you evaluate a patient to see if breathing medication worked?

Answer 73

listen to lungs to see if wheezing improved

Question 74

which patient do you see first: one waiting for discharge someone screaming for morphine or a patient with dyspnea?

Answer 74

patient with dyspnea

Question 75

why are older adults at a higher risk for pneumonia?

Answer 75

lungs are rigid and harder to inflate

Question 76

what step is first in respiratory assessment?

Answer 76

inspection: look for scars assess respiratory rate rhythm depth symmetry of chest movement barrel chest spinal deformities accessory muscle use intact skin

Question 77

when auscultating the lungs, how long should you listen in each spot?

Answer 77

one full ventilation - inhale / exhale

Question 78

what is the correct direction of lung sound auscultation?

Answer 78

side to side to compare

Question 79

how do you determine if there is a pulse deficit?

Answer 79

one nurse counts the radial pulse while one nurse counts the apical pulse for one minute then subtract the difference

Question 80

who is at the greatest risk for developing pneumonia after having a procedure: a 32yo who just had abdominal surgery an 82yo with syncope an 18yo refusing to ambulate or a 45yr with COPD

Answer 80

45yo with COPD - encourage patient to get pneumovax as it is very difficult to recover from pneumonia with COPD

Question 81

which pulse is never assessed bilaterally at the same time?

Answer 81

carotid will cut off brain blood flow

Question 82

post-bp patient needs to do what to prevent pneumonia?

Answer 82

sit up in chair for each mail oral care BID incentive spirometer - 5-10 hourly while awake cough and deep breathe

Question 83

which patients are the most susceptible to environmental pollution?

Answer 83

patients with asthma

Question 84

how can patients prevent COPD and what is the number 1 cause of this disease?

Answer 84

stop smoking

Question 85

what is the cause of high pitched monophonic crowing sound and patient has croup, how high of priority is this patient?

Answer 85

stridor number 1 - caused by an obstruction

Question 86

where is erb's point?

Answer 86

3rd ICS, left of the sternum

Question 87

when you hear S1/S2 but the heart rate is 120 bpm, what is this called?

Answer 87

sinus tachycardia

Question 88

what is the term for short high pitched popping sounds over the lung bases that usually disappear after a few deep breaths and coughs?

Answer 88

fine crackles - alveoli deflated right after waking up

Question 89

primary pacemaker of the heart is?

Answer 89

SA Node

Question 90

what is the term for the low-pitched snoring sound heard over the bases?

Answer 90

Rhonchi

Question 91

if you can't palpate a pulse, what should you use?

Answer 91

doppler

Question 92

where does gas exchange occur?

Answer 92

alveoli

Question 93

what is eupnea?

Answer 93

normal breathing

Question 94

if patient had RR of 30, are they in respiratory distress?

Answer 94

yes

Question 95

how do you calculate cardiac output?

Answer 95

co = sv x hr

Question 96

what causes a soft low pitched rushing sound?

Answer 96

bruit

Question 97

what are 4 findings with a COPD patient?

Answer 97

barreled chest chronic productive cough tachypnea clubbing fatigue accessory muscle use prolonged expiration SpO2 88-92% or lower

Question 98

when taking a manual BP, what artery are you listening to?

Answer 98

brachial

Question 99

where do you assess for a popliteal pulse?

Answer 99

behind the knee

Question 100

what is a normal CRT?

Answer 100

< 2 seconds

Question 101

what is the correct order of techniques for a cardiac assessment?

Answer 101

inspection palpation auscultation (dont have to percuss heart)