Respiratory/cardiovascular

Question 1

Expected findings for long term chronic inadequate or insufficient oxygenation in a client.

Answer 1

COPD, Cyanosis, clubbing, wheezing, SOB, tachycardic

Question 2

COPD

Answer 2

Chronic obstructive pulmonary disease- A group of lung diseases that block airflow and make it difficult to breathe.

Question 3

Cyanosis

Answer 3

a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.

Question 4

Clubbing

Answer 4

An abnormal, distorted, rounded shape of the nail bed. Caused by right sided hearted failure.

Question 5

SOB

Answer 5

Shortness of breath

Question 6

Expected findings for spinal De formalities-

Answer 6

Kyphosis, lordosis, scoliosis

Question 7

Kyphosis

Answer 7

Hunched forward

Question 8

Lordosis

Answer 8

Lumbar/hunched back

Question 9

Scoliosis

Answer 9

Curvature of the spine

Question 10

Early signs and symptoms of hypoxia and hypoxemia.

Answer 10

restlessness, irritability, abnormal breathing, tachycardia, tachypnea, HTN, pallor

Question 11

Late signs and symptoms of hypoxia and hypoxemia

Answer 11

decrease LOC, cyanosis, Increase lactic acid, dysrhythmias, bradycardia, bradypnea, hypotension

Question 12

Expected findings for a person with respiratory failure.

Answer 12

Severe Dyspnea, shortness of breath, use of accessory muscles.

Question 13

How to check oxygenation without pulse oxygenation?

Answer 13

Check cap refill

Question 14

Assessing for cap refill in
peripheral insufficiency can be tested with Allen test because

Answer 14

Has more edema

Question 15

Alternative locations other than the fingers where pulse oximetry may be assessed?

Answer 15

Ear lobe, toes, forehead

Question 16

Correlate the increase the rate in L of oxygen with the percentage of oxygen (% of FiO2)

Answer 16

Room air 21%
1L oxygen=2-4%

Question 17

What transports oxygen in the bloodstream?

Answer 17

Hemoglobin

Question 18

Nursing goal when using oxygen?

Answer 18

Use lowest O2 liter flow needed to manage hypoxia

Question 19

Auscultating Lung sounds

Answer 19

Wheeze, rhonchi, stridor, crackles; assess accessory muscle use, percussion/symmetry

Question 20

Breathing patterns and what that may indicate

Answer 20

Cheyne-stokes: near death; bradypnea: post surgery;
Ataxic-irregular verging dizziness, orthostatic hypodepths

Question 21

How to assess cyanosis or pallor in a darker skinned client

Answer 21

Tongue, fingernail beds, oral mucosa, conjunctiva

Question 22

Know the names and locations of pulse points

Answer 22

Brachial, radial, carotid, popliteal, posterior tib, dorsal is pedis

Question 23

Unexpected findings when assessing a pulse and possible implications

Answer 23

Thready- poor perfusion, diminished=clot/CVT

Question 24

What action does a nurse need to take if a radial pulse is irregular?

Answer 24

Apical pulse for full minute

Question 25

Know the landmarks for assessing (whether palpating or auscultating) the heart sounds/valves.

Answer 25

Aortic-R 2nd, Pulmonic-L 2nd, Erbs point-L 3rd, Tricuspid-L 4th, Mitral-5th intercostal, midclavicular

Question 26

What to expect if a client has mitral valve stenosis

Answer 26

S3-murmur

Question 27

Expected assessment findings for a client with COPD.

Answer 27

Barrel chest, clubbing, acute: tripod position, dyspnea

Question 28

Barrel Chest

Answer 28

a deformity in which the chest becomes expanded in size.

Question 29

Dyspnea

Answer 29

difficult or labored breathing.

Question 30

Expected findings for a client with bradycardia

Answer 30

Hypotension, and dizziness

Question 31

Expected findings for a patient with right sided heart failure,(wreck the body), (think blood flow or sluggish blood flow through the heart)

Answer 31

Edema

Question 32

Expected findings for a patient with left-sided heart failure, (lungs), (think blood flow or sluggish blood flow through the heart)

Answer 32

Rales, crackles, congestion

Question 33

Expected findings in a client with peripheral neuropathy (what might the patient report?)

Answer 33

Sharp pain, pins & needles, burning pain

Question 34

Unexpected findings with arterial or peripheral insufficiencies in the legs

Answer 34

Formation of clots