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PCC1: Campbell > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is an expected finding with right sided heart failure?

A

+4 pitting edema, JVD, and fatigue

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2
Q

what action should the nurse take to auscultate heart sounds?

A

identify S1 and S2

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3
Q

what part of stethoscope is used to identify S1 and S2?

A

diaphragm

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4
Q

which valve will the nurse hear while auscultating the 5th intercostal space, left, midclavicular?

A

mitral valve

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5
Q

what pulse can be found while auscultating the mitral valve (5th intercostal space, left, mid clavicular)?

A

apical pulse
PMI

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6
Q

Does the closing or the opening of valves cause the noise?

A

closing

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7
Q

What causes the S2 sound?

A

the closure of the semi-lunar valves

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8
Q

What is the extra heart sound that can be heard at the beginning of diastole?

A

S3

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9
Q

Where does de-oxygenated blood pumped to from the right ventricle go?

A

the lungs

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10
Q

what carries de-oxygenated blood to the lungs from the right ventricle?

A

pulmonary artery

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11
Q

what is the name for a blowing or swishing sound found in the carotid artery?

A

bruit

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12
Q

what is the name of a blowing or swooshing sound over a heart valve?

A

murmur

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13
Q

what can be used to detect a peripheral pulse that is undetectable through palpation?

A

doppler ultrasound

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14
Q

what skin color change may a client with acute vasoconstriction present with?

A

pallor

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15
Q

what is a client with atherosclerosis (build up in artery wall) at risk for?

A

tissue ischemia

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16
Q

what finding may indicate arterial disease?

A

+1 pedal pulses bilaterally

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17
Q

what terms refers to the strength of a pulse?

A

amplitude

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18
Q

what is the common cause of arterial disease?

A

plaque in the arteries/ atherosclerosis

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19
Q

what assessment finding indicates venous insufficiencies?

A

leg aching relieved by elevation

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20
Q

what assessment finding may represent a deep vein thrombosis? (arterial blood still comes in, but venous blood cannot leave)

A

redness, warmth, swelling and pain in one leg

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21
Q

legs crossed, a cuff too narrow, and an unsupported arm may cause what type of incorrect readings? (blood pressure)

A

false high

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22
Q

what type of incorrect reading would an arm above the heart or a cuff too large cause? (blood pressure)

A

false low

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23
Q

Cough, crackles, and orthopnea are common manifestations for which type of heart failure?

A

left-sided heart failure

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24
Q

Upon auscultating a client’s artery you hear a blowing, swishing, how would you refer to this abnormal heart sound? What causes it?

A

bruit
blood flow turbulence

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25
What heart sound can be heard at the 2nd ICS RSB?
aortic
26
What is a nurse preventing when they protect the skin of a client's nose and ears that use oxygen tubing?
Medical Devise Related Pressure Injuries (MDRPI)
27
What actions should a nurse take when performing denture care for a client?
A) Assess for gum irritation or tenderness. B) Brush the dentures with a toothbrush and denture cleaner. E) Label the denture storage container with the client's name
28
The nurse shines a pen light across a client's right field of vision. When the client's right pupil constricts the nurse will record a positive:
direct light reflex
29
What is referred to as the simultaneous constriction of the opposite pupil?
consensual light reflex
30
PERRLA
pupils are equal, round, and reactive to light and accommodation
31
What will the nurse say when teaching a client about hearing aid care?
"Remove or disconnect the battery when not in use."
32
In what direction should the inner eye be cleaned? Why?
inner canthus to outer canthus -to prevent bacteria or debri from entering the lacrimal duct and causing obstruction or infection
33
The nurse is inspecting a client's tympanic membrane with an otoscope. What findings should the nurse expect in a healthy adult? A tympanic membrane which is
translucent pearly grey
34
The nurse assesses a client's capillary refill and identifies blanching greater than 2 seconds on the lower extremities bilaterally. The nurse will also expect to find:
cool and pale lower extremities
35
Where will the nurse auscultate the anterior apex of the lungs?
above the clavicle
36
What technique will the nurse use to assess resonance of the lungs?
percussion
37
What are high-pitched popping lung sounds on inspiration called?
fine crackles
38
What are medium pitched, equal duration lung sounds heard over the major bronchi called?
bronchovesicular
39
What lung sounds are heard near the sternum and between scapula?
bronchovesicular
40
What is a respiratory rate of 8bpm that is regular called?
bradypnea
41
What would the nurse document for high-pitched musical squeaking that are heard upon auscultation of the lungs?
wheezing
42
What would the nurse document for high pitched, loud, and tubular sounds over the trachea?
normal bronchial breath sounds
43
what is the nurse likely to note on a client with COPD?
AP diameter equal to transverse diameter
44
What is the expected angle of the nail beds?
160 degrees or less
45
What might you expect concerning an individuals nail beds who has a chronic lung condition? Why?
180 degrees or more/clubbing long term hypoxia to the fingers
46
What are the three key components of assessing a client's respirations?
rate, depth, and rhythm
47
What is expected with tactile fremitus (vibrations; ex. having patient say "99" while palpating)?
symmetry
48
What is referred to as soft, low rustling breath sounds?
vesicular
49
What might the nurse expect with right sided heart failure?
JVD
50
What produces the S1 sound?
the closure of the tricuspid and mitral valves
51
What is an extra heart sound that can be heard before S1?
S4
52
Where is blood pumped after the left ventricle?
aorta
53
What is a blowing or swooshing sound in the heart?
murmur
54
What skin color change may a client with an SpO2 of 80% have?
cyanosis
55
Shiny, hairless legs are an indicator of what condition?
arterial disease
56
Red/brown color on legs may indicate what type of a blood vessel insufficiency?
venous
57
What may Redness, Warmth, Swelling, and Pain in 1 Leg indicate?
DVT (deep vein thrombosis)
58
What technique will the nurse utilize to assess for resonance?
percussion
59
What are low pitched, bubbly lung sounds that are heard on inspiration called?
course crackles
60
What are the medium pitched, equal duration lung sounds that are heard over the major bronchi called?
bronchovesicular
61
barking or honking auscultated on inspiration of the trachea?
stridor
62
The nurse auscultates high pitched, loud, and tubular sounds over the trachea and documents:
normal bronchial breath sounds
63
Which assessment will the nurse palpate the chest wall while the cllient states 99?
tactile fremitus
64
How should artificial eyes be cleaned?
as needed with soap and water
65
What should denture care be preformed with?
soft tooth brush and toothpaste
66
Should you irrigate someones ear with a perforated tympanic membrane?
no
67
What does the Webber test indicate?
hearing loss
68
What is an expected finding of the neck?
tracheae midline
69
What tool is used to assess visual acuity?
Snellen chart
70
What is PERRLA?
pupils equal round and reactive to light and accommodation
71
How will the nurse BEST assess a client's ability to brush their teeth?
wash them brush their teeth
72
What is the appropriate measure to prevent aspiration while brushing an unconscious client's teeth?
suction
73
When should denture care be performed?
after meals and at bedtime
74
What compares air and bone conduction?
Rinne test
75
With what population is an expected production of cerumen (earwax) expected?
elderly adult client
76
Where will the nurse auscultate the anterior apex of the lungs?
above the clavivle
77
Where will the nurse auscultate the anterior apex of the lungs?
above the clavicle
78
What are high pitched, popping lung sounds heard on inspiration called?
fine crackles
79
How do you assess a patient for near vision?
have them read printed material under adequate lighting, and wear their glasses if they have them
80
How can you assess a patient's distant vision?
have them stand 6.1meters/20ft away from a Snellen chart
81
What does a larger denominator mean for Snellen chart results?
the higher the denominator, the worse the vision
82
How often should individuals 40 and under get an eye exam?
every 3-5 yrs
83
How often should individuals over 65 get an eye exam?
every year
84
What is strabismus?
crossed eyes
85
What is ptosis?
drooping of eyelid over pupil
86
What is expected of the sclera?
white porcelain
87
What is expected of the cornea?
shiny, transparent, and smooth
88
What is expected of the pupils?
black, round, regular, and equal, 3-7mm in diameter
89
What is the first step of assessing blood pressure?
palpate brachial pulse
90
3rd intercostal space, left sternal border
Erb's point
91
What is MDRPI?
medical device related pressure injury
92
What are steps of denture care?
A) Assess for gum irritation or tenderness. B) Brush the dentures with a toothbrush and denture cleaner. C) Label the denture storage container with the client's name.
93
myopia
near sightedness
94
orthopnea
sob while laying down
95
dyspnea
labored breathing
96
nystagmus
uncontrolled vibrations of the eye
97
What does a whistling sound indicate with hearing aids?
incorrect earmold insertion, improper fit of aid, or buildup of earwax or fluid.
98
How should nurse clean external eye?
wipe from inner canthus to outer canthus

PCC1: Campbell (5 decks)

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