Exam 2 Flashcards
What is an expected finding with right sided heart failure?
+4 pitting edema, JVD, and fatigue
what action should the nurse take to auscultate heart sounds?
identify S1 and S2
what part of stethoscope is used to identify S1 and S2?
diaphragm
which valve will the nurse hear while auscultating the 5th intercostal space, left, midclavicular?
mitral valve
what pulse can be found while auscultating the mitral valve (5th intercostal space, left, mid clavicular)?
apical pulse
PMI
Does the closing or the opening of valves cause the noise?
closing
What causes the S2 sound?
the closure of the semi-lunar valves
What is the extra heart sound that can be heard at the beginning of diastole?
S3
Where does de-oxygenated blood pumped to from the right ventricle go?
the lungs
what carries de-oxygenated blood to the lungs from the right ventricle?
pulmonary artery
what is the name for a blowing or swishing sound found in the carotid artery?
bruit
what is the name of a blowing or swooshing sound over a heart valve?
murmur
what can be used to detect a peripheral pulse that is undetectable through palpation?
doppler ultrasound
what skin color change may a client with acute vasoconstriction present with?
pallor
what is a client with atherosclerosis (build up in artery wall) at risk for?
tissue ischemia
what finding may indicate arterial disease?
+1 pedal pulses bilaterally
what terms refers to the strength of a pulse?
amplitude
what is the common cause of arterial disease?
plaque in the arteries/ atherosclerosis
what assessment finding indicates venous insufficiencies?
leg aching relieved by elevation
what assessment finding may represent a deep vein thrombosis? (arterial blood still comes in, but venous blood cannot leave)
redness, warmth, swelling and pain in one leg
legs crossed, a cuff too narrow, and an unsupported arm may cause what type of incorrect readings? (blood pressure)
false high
what type of incorrect reading would an arm above the heart or a cuff too large cause? (blood pressure)
false low
Cough, crackles, and orthopnea are common manifestations for which type of heart failure?
left-sided heart failure
Upon auscultating a client’s artery you hear a blowing, swishing, how would you refer to this abnormal heart sound? What causes it?
bruit
blood flow turbulence
What heart sound can be heard at the 2nd ICS RSB?
aortic
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)
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
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
What is referred to as the simultaneous constriction of the opposite pupil?
consensual light reflex
PERRLA
pupils are equal, round, and reactive to light and accommodation
What will the nurse say when teaching a client about hearing aid care?
“Remove or disconnect the battery when not in use.”
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
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
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
Where will the nurse auscultate the anterior apex of the lungs?
above the clavicle
What technique will the nurse use to assess resonance of the lungs?
percussion
What are high-pitched popping lung sounds on inspiration called?
fine crackles
What are medium pitched, equal duration lung sounds heard over the major bronchi called?
bronchovesicular
What lung sounds are heard near the sternum and between scapula?
bronchovesicular
What is a respiratory rate of 8bpm that is regular called?
bradypnea
What would the nurse document for high-pitched musical squeaking that are heard upon auscultation of the lungs?
wheezing
What would the nurse document for high pitched, loud, and tubular sounds over the trachea?
normal bronchial breath sounds
what is the nurse likely to note on a client with COPD?
AP diameter equal to transverse diameter
What is the expected angle of the nail beds?
160 degrees or less
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
What are the three key components of assessing a client’s respirations?
rate, depth, and rhythm
What is expected with tactile fremitus (vibrations; ex. having patient say “99” while palpating)?
symmetry
What is referred to as soft, low rustling breath sounds?
vesicular
What might the nurse expect with right sided heart failure?
JVD
What produces the S1 sound?
the closure of the tricuspid and mitral valves
What is an extra heart sound that can be heard before S1?
S4
Where is blood pumped after the left ventricle?
aorta
What is a blowing or swooshing sound in the heart?
murmur
What skin color change may a client with an SpO2 of 80% have?
cyanosis
Shiny, hairless legs are an indicator of what condition?
arterial disease
Red/brown color on legs may indicate what type of a blood vessel insufficiency?
venous
What may Redness, Warmth, Swelling, and Pain in 1 Leg indicate?
DVT (deep vein thrombosis)
What technique will the nurse utilize to assess for resonance?
percussion
What are low pitched, bubbly lung sounds that are heard on inspiration called?
course crackles
What are the medium pitched, equal duration lung sounds that are heard over the major bronchi called?
bronchovesicular
barking or honking auscultated on inspiration of the trachea?
stridor
The nurse auscultates high pitched, loud, and tubular sounds over the trachea and documents:
normal bronchial breath sounds
Which assessment will the nurse palpate the chest wall while the cllient states 99?
tactile fremitus
How should artificial eyes be cleaned?
as needed with soap and water
What should denture care be preformed with?
soft tooth brush and toothpaste
Should you irrigate someones ear with a perforated tympanic membrane?
no
What does the Webber test indicate?
hearing loss
What is an expected finding of the neck?
tracheae midline
What tool is used to assess visual acuity?
Snellen chart
What is PERRLA?
pupils equal round and reactive to light and accommodation
How will the nurse BEST assess a client’s ability to brush their teeth?
wash them brush their teeth
What is the appropriate measure to prevent aspiration while brushing an unconscious client’s teeth?
suction
When should denture care be performed?
after meals and at bedtime
What compares air and bone conduction?
Rinne test
With what population is an expected production of cerumen (earwax) expected?
elderly adult client
Where will the nurse auscultate the anterior apex of the lungs?
above the clavivle
Where will the nurse auscultate the anterior apex of the lungs?
above the clavicle
What are high pitched, popping lung sounds heard on inspiration called?
fine crackles
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
How can you assess a patient’s distant vision?
have them stand 6.1meters/20ft away from a Snellen chart
What does a larger denominator mean for Snellen chart results?
the higher the denominator, the worse the vision
How often should individuals 40 and under get an eye exam?
every 3-5 yrs
How often should individuals over 65 get an eye exam?
every year
What is strabismus?
crossed eyes
What is ptosis?
drooping of eyelid over pupil
What is expected of the sclera?
white porcelain
What is expected of the cornea?
shiny, transparent, and smooth
What is expected of the pupils?
black, round, regular, and equal, 3-7mm in diameter
What is the first step of assessing blood pressure?
palpate brachial pulse
3rd intercostal space, left sternal border
Erb’s point
What is MDRPI?
medical device related pressure injury
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.
myopia
near sightedness
orthopnea
sob while laying down
dyspnea
labored breathing
nystagmus
uncontrolled vibrations of the eye
What does a whistling sound indicate with hearing aids?
incorrect earmold insertion, improper fit of aid, or buildup of earwax or fluid.
How should nurse clean external eye?
wipe from inner canthus to outer canthus
