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PCC 1 NRSE-2350-001 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

The nurse may suspect right sided heart failure based on what assessment findings?

A

JVD, edema, weight gain

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2
Q

What part of the stethoscope should the nurse use to auscultate heart sounds?

A

Use the diaphragm of the stethoscope first, then follow up with the bell to listen for murmurs

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3
Q

Where do you begin when auscultating the heart sounds?

A

The 2ICS at the RSB

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4
Q

The nurse auscultating over the 2nd intercostal space right Sternal border will hear:

A

The aortic valve area

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5
Q

What is an extra heart sound heard before S1?

A

S4

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6
Q

Oxygenated blood is pumped from the left ventricle to the:

A

Aortic valve to aorta

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7
Q

What is a blowing or swishing sound found over the mitral valve?

A

Murmur

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8
Q

A client with SPO2 of 80% may have which skin color change?

A

Cyanosis

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9
Q

What findings indicate arterial disease?

A

Shiny, hairless legs

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10
Q

What assessment findings indicate venous insufficiency?

A

Red/brown color of the legs, pitting edema, pain

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11
Q

What assessment finding indicates DVT?

A

Erythema, edema, warmth, and pain in 1 leg

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12
Q

What should be done to get an accurate BP reading?

A

Arm at level of heart, cuff 1-2 inches above brachial pulse, legs uncrossed, feet flat on the floor

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13
Q

What technique is used to assess resonance?

A

Percussion

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14
Q

What are low pitched bubbling lung sounds on inspiration called?

A

Course crackles

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15
Q

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

A

Bronchovesicular

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16
Q

A respiratory rate of 8bpm and the depth is shallow is called what?

A

Hypoventilation

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17
Q

What is the difference between Brady/tachypnea and hypo/hyperventilation

A

The depth of the respirations

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18
Q

The nurse hears barking or honking on inspiration on auscultation of the trachea and documents:

A

Stridor

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19
Q

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

A

Normal bronchial breath sounds

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20
Q

What will a nurse document a note for nails in a client with COPD?

A

Nail bed angle of 190 degrees

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21
Q

What describes if the breath is deep or shallow?

A

Depth

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22
Q

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

A

Tactile fremitus

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23
Q

What are expected findings of the neck?

A

No JVD, trachea=midlne, non palpable lymph nodes

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24
Q

Artificial eyes should be cleaned…

A

As needed with soap and water

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25
T/F 20/20 sees better than 20/15
False; 20/20= you can see at 20 ft what a normal person sees at 20 ft 20/15= you can see at 20 ft what a normal person can see from 15 ft
26
Denture care should be performed with…
A soft toothbrush and toothpaste
27
A perforated TM is a contraindication for ear irrigation T/F
True
28
T/F The Webber test indicates that there is hearing loss
True
29
What are expected findings for the eye assessment?
Pupil round and regular, PERRLA, no swelling, redness, discharge, or lesions, evenly distributed eyelashes, conjunctiva clear and red/pink, sclera white, cornea clear and smooth, Iris even coloration & flat, round regular shape, lacrimal gland has no discharge
30
What are unexpected findings in an eye assessment?
Swelling, redness, discharge, lesions, unequal pupillary response, no accommodation, sclera not white, conjunctiva not red/pink and moist, lacrimal gland has discharge
31
What techniques do you use in an eye assessment?
Inspect with penlight, palpate to check conjunctiva and sclera (pulling lids)
32
What are expected findings for an ear assessment?
Ears symmetrical and in line, no discharge or redness, no difficulty hearing
33
What are unexpected findings for an ear assessment?
Failed Webber or Rinne tests, discharge, redness, unsymmetrical,
34
What techniques do you use in an ear assessment?
Inspect visually; Webber and Rinne tests
35
what are expected findings in a hearing assessment?
Webber test: pt can hear the ringing of the tuning fork in both ears for equal amounts of time (conduction and sensineural)
36
What are expected findings in a vision assessment?
20/20 vision (person can see what other people typically see at 20 feet from the Snellen chart)
37
What are expected findings in a mouth assessment?
Lips are not dry or cracked with no discoloration, tongue is moist with no swelling or lesions and is freely moveable, cheeks are smooth and moist with no lesions, hard palate is moist and pink and smooth with no lesions, soft palate is moveable and moist and pink with no swelling or lesions or discoloration. Gum lines have no recession, swelling, redness, lesions, or tenderness. Teeth are all present with no deformities or integrity issues
38
What are unexpected findings in a mouth assessment?
Lips are discolored, cracked, have lesions; tongue is dry, white ( or another color), not freely movable, swollen, tender, and has lesions; cheeks have lesions and are dry and discolored; hard palate is dry, discolored, has lesions; soft palate is not moveable, is dry, discolored, and has lesions; gum lines have recession, swelling , redness, lesions, bleeding, are dry, and are discolored; teeth are missing, have impaired integrity, or have some sort of deformity.
39
What are expected findings in a head and neck assessment?
Normocephalic, trachea midline, hair evenly distributed, lymph nodes are not palpable, no discoloration or color differences, no lesions, no impaired mobility
40
What are unexpected findings in a head and neck assessment?
Head is not a normal shape/contour, trachea is not midline or intact, hair is not evenly distributed/ excessive hair loss, lymph nodes are palpable, color differences between head and neck, discoloration between skin tone and what is seen on head and neck, lesions present, impaired mobility
41
What should be noted about the trachea?
It is intact and midline
42
What is important to know about oral care in an unconscious patient?
They are at an increased risk for aspiration; limited excess fluid on toothette and keep the head of the bed up!
43
How should dentures be stored?
In a moist room temperature container
44
What temperature water should be used for denture care?
Warm; hot and cold will crack/damage them
45
What should be avoided when performing ear irrigation?
Sticking things down the ear canal- the eardrum is closer than you think!
46
If the TM is not intact, should you irrigate the ear?
No
47
How do you take care of artificial eyes?
Use warm water, use soap (do not use alcohol based products), let is air dry
48
How do you take care of your own eyes?
Eye exam regularly, avoid irritants, wear sunglasses when outdoors to protect from UV rays
49
What are the S/S of heart failure?
JVD, edema, shiny and hairless legs, crackles, fatigue,
50
In what pattern do you ausculate for lung sounds?
Hourglass (avoiding bones- sternum and scapulae)
51
What valve area is located at the 2ICS RSB?
Aortic valve
52
What valve area is located at the 2 ICS LSB?
Pulmonic valve
53
What valve area is located at the 4-5th ICS RSB?
Tricuspid valve
54
What valve area is located at the 5th ICS L Midclavicular line?
Mitral valve
55
Where is Erb’s point located at?
4TH ICS RSB
56
Where is the apical pulse taken?
At the 5th ICS L Midclavicular line
56
Where is the apical pulse taken?
At the 5th ICS L Midclavicular line
57
What is the PMI?
Point of maximal impulse
58
What are normal heart sounds?
S1 and S2
59
What is systole?
Ventricular contraction; top number in a BP
60
What is diastole?
Ventricular filling/rest; bottom number of BP
61
What valves close as the ventricles relax to build pressure?
The semilunar valves (pulmonic and aortic)
62
What valves close second as the ventricles contract to prevent backflow?
Tricuspid and Mitral valves
63
Where does the impulse originate in the heart prior to the myocardium contracting?
SA node
64
What are unexpected findings during auscultation of the heart
Murmurs, extra heart sounds (S3 and S4)
65
What are unexpected findings on palpation and auscultation of the heart and neck vessels?
Heart: thrills (purring sound), murmurs, extra heart sounds, abnormal apical pulse Neck vessels: JVD, bruit (swooshing sound), wavelike pulsations on the side of the neck
66
What are the pulse techniques and expected values?
Radial (inside of the wrist, thumb side), brachial (inside the inner elbow towards pinky side/middle), pedal (top of foot following bones of big toe and second toe), carotid (side of neck on anterior side), femoral (near groin medial side of leg), popliteal (behind the knee); expected pulse= 60-100 bpm
67
What are the BP techniques and expected values?
Cuff 2 inches above antecubital (where brachial pulse is), ask what usual BP is and pump 30 above stated systolic, release pressure slowly and listen for first and last sounds for BP; place BP cuff around forearm or thigh; expected values= 110-120/60-70
68
What is DVT?
Deep vein thrombosis
69
Peripheral artery disease and S/S

PCC 1 NRSE-2350-001 (5 decks)

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