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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
Q

What heart sound can be heard at the 2nd ICS RSB?

A

aortic

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26
Q

What is a nurse preventing when they protect the skin of a client’s nose and ears that use oxygen tubing?

A

Medical Devise Related Pressure Injuries (MDRPI)

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27
Q

What actions should a nurse take when performing denture care for a client?

A

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

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28
Q

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:

A

direct light reflex

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29
Q

What is referred to as the simultaneous constriction of the opposite pupil?

A

consensual light reflex

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30
Q

PERRLA

A

pupils are equal, round, and reactive to light and accommodation

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31
Q

What will the nurse say when teaching a client about hearing aid care?

A

“Remove or disconnect the battery when not in use.”

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32
Q

In what direction should the inner eye be cleaned? Why?

A

inner canthus to outer canthus
-to prevent bacteria or debri from entering the lacrimal duct and causing obstruction or infection

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33
Q

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

A

translucent pearly grey

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34
Q

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:

A

cool and pale lower extremities

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35
Q

Where will the nurse auscultate the anterior apex of the lungs?

A

above the clavicle

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36
Q

What technique will the nurse use to assess resonance of the lungs?

A

percussion

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37
Q

What are high-pitched popping lung sounds on inspiration called?

A

fine crackles

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38
Q

What are medium pitched, equal duration lung sounds heard over the major bronchi called?

A

bronchovesicular

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39
Q

What lung sounds are heard near the sternum and between scapula?

A

bronchovesicular

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40
Q

What is a respiratory rate of 8bpm that is regular called?

A

bradypnea

41
Q

What would the nurse document for high-pitched musical squeaking that are heard upon auscultation of the lungs?

A

wheezing

42
Q

What would the nurse document for high pitched, loud, and tubular sounds over the trachea?

A

normal bronchial breath sounds

43
Q

what is the nurse likely to note on a client with COPD?

A

AP diameter equal to transverse diameter

44
Q

What is the expected angle of the nail beds?

A

160 degrees or less

45
Q

What might you expect concerning an individuals nail beds who has a chronic lung condition? Why?

A

180 degrees or more/clubbing
long term hypoxia to the fingers

46
Q

What are the three key components of assessing a client’s respirations?

A

rate, depth, and rhythm

47
Q

What is expected with tactile fremitus (vibrations; ex. having patient say “99” while palpating)?

A

symmetry

48
Q

What is referred to as soft, low rustling breath sounds?

A

vesicular

49
Q

What might the nurse expect with right sided heart failure?

A

JVD

50
Q

What produces the S1 sound?

A

the closure of the tricuspid and mitral valves

51
Q

What is an extra heart sound that can be heard before S1?

A

S4

52
Q

Where is blood pumped after the left ventricle?

A

aorta

53
Q

What is a blowing or swooshing sound in the heart?

A

murmur

54
Q

What skin color change may a client with an SpO2 of 80% have?

A

cyanosis

55
Q

Shiny, hairless legs are an indicator of what condition?

A

arterial disease

56
Q

Red/brown color on legs may indicate what type of a blood vessel insufficiency?

A

venous

57
Q

What may Redness, Warmth, Swelling, and Pain in 1 Leg indicate?

A

DVT (deep vein thrombosis)

58
Q

What technique will the nurse utilize to assess for resonance?

A

percussion

59
Q

What are low pitched, bubbly lung sounds that are heard on inspiration called?

A

course crackles

60
Q

What are the medium pitched, equal duration lung sounds that are heard over the major bronchi called?

A

bronchovesicular

61
Q

barking or honking auscultated on inspiration of the trachea?

A

stridor

62
Q

The nurse auscultates high pitched, loud, and tubular sounds over the trachea and documents:

A

normal bronchial breath sounds

63
Q

Which assessment will the nurse palpate the chest wall while the cllient states 99?

A

tactile fremitus

64
Q

How should artificial eyes be cleaned?

A

as needed with soap and water

65
Q

What should denture care be preformed with?

A

soft tooth brush and toothpaste

66
Q

Should you irrigate someones ear with a perforated tympanic membrane?

A

no

67
Q

What does the Webber test indicate?

A

hearing loss

68
Q

What is an expected finding of the neck?

A

tracheae midline

69
Q

What tool is used to assess visual acuity?

A

Snellen chart

70
Q

What is PERRLA?

A

pupils equal round and reactive to light and accommodation

71
Q

How will the nurse BEST assess a client’s ability to brush their teeth?

A

wash them brush their teeth

72
Q

What is the appropriate measure to prevent aspiration while brushing an unconscious client’s teeth?

A

suction

73
Q

When should denture care be performed?

A

after meals and at bedtime

74
Q

What compares air and bone conduction?

A

Rinne test

75
Q

With what population is an expected production of cerumen (earwax) expected?

A

elderly adult client

76
Q

Where will the nurse auscultate the anterior apex of the lungs?

A

above the clavivle

77
Q

Where will the nurse auscultate the anterior apex of the lungs?

A

above the clavicle

78
Q

What are high pitched, popping lung sounds heard on inspiration called?

A

fine crackles

79
Q

How do you assess a patient for near vision?

A

have them read printed material under adequate lighting, and wear their glasses if they have them

80
Q

How can you assess a patient’s distant vision?

A

have them stand 6.1meters/20ft away from a Snellen chart

81
Q

What does a larger denominator mean for Snellen chart results?

A

the higher the denominator, the worse the vision

82
Q

How often should individuals 40 and under get an eye exam?

A

every 3-5 yrs

83
Q

How often should individuals over 65 get an eye exam?

A

every year

84
Q

What is strabismus?

A

crossed eyes

85
Q

What is ptosis?

A

drooping of eyelid over pupil

86
Q

What is expected of the sclera?

A

white porcelain

87
Q

What is expected of the cornea?

A

shiny, transparent, and smooth

88
Q

What is expected of the pupils?

A

black, round, regular, and equal, 3-7mm in diameter

89
Q

What is the first step of assessing blood pressure?

A

palpate brachial pulse

90
Q

3rd intercostal space, left sternal border

A

Erb’s point

91
Q

What is MDRPI?

A

medical device related pressure injury

92
Q

What are steps of denture care?

A

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
Q

myopia

A

near sightedness

94
Q

orthopnea

A

sob while laying down

95
Q

dyspnea

A

labored breathing

96
Q

nystagmus

A

uncontrolled vibrations of the eye

97
Q

What does a whistling sound indicate with hearing aids?

A

incorrect earmold insertion, improper fit of aid, or buildup of earwax or fluid.

98
Q

How should nurse clean external eye?

A

wipe from inner canthus to outer canthus

PCC1: Campbell (5 decks)

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