Exam 3

Question 1

Cardiovascular assessment: Inspection

Answer 1

-Raise HOB 30-45 degrees
-Inspect rise and fall of chest
-Check neck veins
-Check for distention
-Arterial pulses
-PMI (5th intercostal space at the midclavicular line)
-skin, temp, evenly distributed hair
-nail beds and clubbing
-edema

Question 2

Cardiovascular assessment: Palpation

Answer 2

-carotid arteries
-PMI
-peripheral pulses (rhythm, rate, quality) (+2)
-skin for temp, turgor, moisture, edema, cap refill

Question 3

Cardiovascular assessment: Auscultation

Answer 3

-rate (expected, tacky, brady)
-rhythm
-S1 and S2
-possible extra heart sounds

Question 4

What is the S1 sound?

Answer 4

-mitral and tricuspid closure

Question 5

What is the S2 sound?

Answer 5

-aortic and pulmonary closure

Question 6

What can we use if a pulse is not palpable?

Answer 6

portable doppler probe

Question 7

use of bell vs diaphragm

Answer 7

bell = low-frequency abnormal sounds

diaphragm: high-frequency normal sounds

Question 8

interventions for chest pain

Answer 8

-ask subjective questions
-pulse ox and vitals
-rapid response
-pt in semi fowlers position to decrease exertion
-ECG
-non rebreather mask

Question 9

Cardiovascular expected changes with aging

Answer 9

-rise in systolic BP
-thickening of blood vessels
-thickening of left ventricle
-decreased CO and strength of contractions
-heart valves stiffen
-decrease in peripheral circulation
-irregular rhythms
-postural/orthostatic hypotension

Question 10

cardiovascular health promotion strategies

Answer 10

-annual screenings and follow ups
-physical activity
-stress reduction/coping strategies
-nutrition
-smoking cessation

Question 11

Respiratory assessment: Inspection

Answer 11

-Appearance: position, evidence of respiratory distress, thorax shape, diameter, symmetry, and movement
-A/P diameter to transverse diameter is 1:2
-vital signs
-RR, depth, rhythm, presence of cough, color of skin/nails/mucous membranes, trachea positionin

Question 12

Respiratory assessment: palpation

Answer 12

-palpate anteriorly and posteriorly, note muscle mass, bone defects, nodules, masses, crepitus
-ask about tenderness

Question 13

Respiratory assessment: Percussion

Answer 13

Provider

Question 14

Respiratory assessment: Auscultation

Answer 14

-listen to breath sounds

Question 15

Adventitious breath sounds

Answer 15

-Crackles/rales: fine, course “bubble
-Wheezes, high pitched whistling, louder on expiration, narrowing/inflammation
-Rhonchi: course, low pitched, fluid/mucous, can clear with cough
-Stridor: noisy, high pitched, blockage/narrowing of upper airway, possibly life threatening
-Pleural friction rub: dry, grating, rubbing, inflammation

Question 16

minimal air movement nursing interventions

Answer 16

-ask subjective questions
-Temp, RR, O2
-elevate HOB –> encourage deep breathing and cough –> O2 therapy –> notify provider –> document –> reassess

Question 17

Respiratory aging considerations

Answer 17

-reduced chest expansion and functional alveoli
-kyphosis due to osteoporosis and weakened cartilage
-reduced immune function
-decrease in cough reflex
-decrease in cilia functioning

Question 18

respiratory health promotion behaviors

Answer 18

-exercise
-smoking cessation
-immunizations

Question 19

Abdomen auscultation order

Answer 19

RLQ only or like a rainbow (RLQ, RUQ, LUQ, LLQ)

Question 20

Abdomen assessment: palpation

Answer 20

-palpate all 4 quadrants, light 1 cm depth, one hand, circular motion
-do not palpate visible pulsations
-note masses/tenderness
-note any verbal/nonverbal pain cues

Question 21

What is the correct order of assessment for abdomen?

Answer 21

-inspection, auscultation, percussion, palpation

Question 22

Abdomen/GI aging considerations

Answer 22

-weaker abdominal muscles and more adipose tissue
-dental caries, periodontal (gum) disease
-decreased number of taste buds, sense of smell lessens
-less saliva (xeostomia)
-lower esophageal and intestinal motility –> constipation
-decreased HCL acid secretions
-social disparities = risk for decreased food intake and ability to obtain nutritious food

Question 23

GI health promotion strategies

Answer 23

-exercise
-diet: well balanced, probiotics, fiber, water
-screenings: occult blood, colonoscopy/sigmoidoscopy (ages 45-75 every 10 years for average risk)

Question 24

5 rights of medication admin

Answer 24

1. right person (2 identifiers)
2. right medication
3. right route
4. right dose
5. right time
6. documentation

Question 25

3 checks of med admin

Answer 25

1. safety check (compare MAR to physicians orders)
2. 1st check: pulling meds
3. 2nd check: prep meds
4. 3rd check: at pts bedside before administering meds

Question 26

types of routes for meds

Answer 26

-enteral/oral
-topical/transdermal
-parental

Question 27

oral/enteral meds safety considerations

Answer 27

-assess ability to swallow
-don’t crush/split ER or SR capsules
-label expiration date for multi dose
-shake liquids

Question 28

topical/transdermal meds safety considerations

Answer 28

-remove old patch before replacing with new one
-rotate sites
-eye drop in lower eyelid
-ear drops = pt lays on side
-inhaler

Question 29

parental meds safety considerations

Answer 29

-proper needle size and gauge
-proper angle of administration
-needle stick prevention, no recapping and use sharps container