Exam 3 Study Guide: Quizlet Flashcards
the nurse is performing a respiratory assessment and detects a low pitch, sot sound. The inspiratory phase is longer than expiration. The nurse interprets this as?
vesicular sound
when percussing the chest, what sound would the nurse expect to hear over the lungs?
resonance
the nurse auscultates an extra sound over the left lower lobe. The nurse should: document finding,
Ask client to cough
upon auscultation the nurse detects an extra gurgling, expiratory sound in the upper airways. the nurse interprets this as?
rhonchi
inspection of the chest includes assessing the anterior-posterior: lateral ratio. the normal finding for an adult is:
1:2
the nurse is performing a cardiac assessment. Which site is best for palpating the PMI?
apex
the nurse detects a trill while palpating the carotids. what sound would the nurse expect to hear when auscultating the carotids?
bruit
how would the nurse differentiate carotid from venous pulsations?
jugulars affected by breathing
during cardiac auscultation, the nurse detects a low pitch early diastolic sound at the apex. the nurse interprets this as:
S3
there are many different causes of chest pain. Which area should be addressed first when a client presents with chest pain?
cardiac
where are bronchovesicular sounds heard?
over major bronchi near sternal notch
where are bronchial sounds heard?
over trachea or larynx, up by clavicle
where are vesicular sounds heard?
over peripheral lung fields - mostly what we listen to
Causes, sounds, and associated conditions of Rales/Crackles?
caused by air passing through fluid
sounds like bubbling/crackling like rice crispy
soft, high-pitched, very brief
usually on inspiration
pulmonary edema
atelectasis
fibrosis
pneumonia
causes, sounds, and associated conditions of wheezes?
narrowing of airway passages
can be heard on inspiration or expiration
asthma
COPD
cause, sounds, and associated conditions of rhonchi?
mucous secretions in large airway
coarse, snoring, low-pitched, continuous sounds
usually on expiration but can be on inspiration as well
might snore from mucous build up
may clear with coughing
pneumonia
bronchitis
emphysema
cause, sounds, and associated conditions of friction rub?
inflammation in pleural spaces
high-pitched grating or rubbing sound
best heard over lower lateral lungs
infection/inflammation of pleura - pleuritis
cause, sounds, and associated conditions of stridor?
medical emergency - partial airway obstruction
child swallowed object, laryngeal spasms, or epiglottitis
high-pitched continuous honking sound
prominent on inspiration
cause, sounds, and associated conditions of grunting
retention of air in the lungs
high-pitched tubular sound
heard on expiration
emphysema - unable to fully exhale
what is the pathway of the electrical impulse through the heart?
starts in the right atria at the SA node
across the internodal pathways to left atria
AV node then bundle of his where there is a short pause
down right and left bundle branches to purkinje fibers which contract the ventricles
what is the pathway of blood through the heart?
superior and inferior vena cava
right atrium
tricuspid valve
right ventricle
pulmonary valve
pulmonary artery
lungs
pulmonary vein
left atrium
mitral valve
left ventricle
aorta
body
what are symptoms of left-sided heart failure?
blood backs up into the lungs
pulmonary congestion
cough
blood-tinged sputum
tacypnea
tachycardia
restless
confusion
dyspnea - worse with exertion
cyanosis - check MM/sclera in patient with darker skin tone
fatigue
lung sounds: crackles and wheezes
what are the symptoms of right-sided heart failure?
blood backs up coronary vein
fatigue
increased JVD
ascites
hepatosplenomegaly
anorexia
weight gain
edema
what are modifiable risk factors for hypertension?
alcohol intake
smoking
stress
obesity
stress
diet
lack of exercise
what are non-modifiable risk factors for hypertension?
family hx
age 65 and older
what are symptoms of peripheral artery disease?
hair loss on lower limbs
weak or absent peripheral pulses
ulcerations in toes and lower limbs that do not bleed
pain with walking
legs cool to the touch
what are symptoms of peripheral venous disease?
develop wounds that usually have drainage
skin gets very thick and brown
how many lobes are in each lung?
right = 3
left = 2
what is the order of techniques for the respiratory assessment?
inspection, palpation, percussion, auscultation
lining of the lungs
pleura
major airway passages of the lungs
bronchi
smaller airway passages of the lungs
bronchioles
location of gas exchange
alveoli
where can you check for cyanosis?
conjuctiva
oral mucous membranes
anywhere without heavy pigmentation
what lung changes occur in an older adult?
loss of tissue elasticity
increased rigidity
difficult to inflate
increased risk for pneumonia
what is the benefit of increased hydration to a pneumonia patient?
thin secretions
who is at increased risk for pneumonia?
COPD patients
older adults
what are typical subjective and inspection findings for COPD patient?
subjective:
dyspnea
chronic productive cough
fatigue
inspection:
tachypnea
productive cough
clubbing
increased AP diameter
accessory muscle use
short shallow breaths
prolonged expiration
O2 sat levels low 88-89% or even lower
what are typical percussion and auscultation findings for a COPD patient?
percussion:
decreased diaphragmatic excursion
hyperresonance due to trapped air
auscultation:
decreased breath sounds
possible occasional wheeze and crackles
what is a side effect of opioids?
CNS depression - bradypnea
shallow respirations
what is normal RR?
12 - 20 bpm
what is bradypnea RR?
< 12 bpm
what is tachypnea RR?
> 20 bpm
what are ways to prevent respiratory complications post op?
encourage inspiratory spirometer (IS) every hour while awake
brush teeth BID
encourage the client to cough and deep breath
sit in chair for each meal
what is the order of techniques for cardiovascular assessment?
inspection, palpation, auscultation
(no percussion)
what do you need to do if the radial pulse is irregular?
auscultate the apical pulse for a full minute
what is a pulse deficit?
difference between the radial and apical pulse
what do each of the pulse scores mean?
0 = absent pulse
1+ = weak, diminished, thready
2+ = normal, brisk
3+ = full
4+ = bounding
in the absence of disease, how do you characterize peripheral pulses?
symmetrical strength
quality
quantity
how does systolic BP, CO, and arterial walls change with age?
systolic BP: increases
CO: decreases
arterial walls: thicken
what is the meaning of systolic blood pressures?
how much pressure is exerted against artery walls during ventricular contraction
what is the meaning of diastolic blood pressures?
how much pressure is exerted against artery walls while the heart is resting between beats
what is the criteria and symptoms orthostatic hypotension?
drop in blood pressure >20 systolic with position changes
dizziness, weakness, and fainting
what position and tools are required to assess for JVD?
elevate patients head to 45 degrees or semi-fowlers
use a penlight
what is occurring during S1 heart sounds?
S1 = lub
AV valve (mitral and tricuspid) closure
what is occurring during S2 heart sounds?
S2 = dub
aortic and pulmonic valve closure and marks the beginning of diastole
what causes a swishing sound during cardiovascular auscultation?
murmurs -
could indicate the presence of heart disease and valve malfunction
what 4 peripheral pulses can be palpated in the lower extremities?
femoral pulse
popliteal pulse
posterior tibial
dorsalis pedis
what symptoms would have higher priority than chest pain?
airway and breathing - ex dyspnea
chest pain abnormal cardiovascular finding and related to curculation
what is a barreled chest and what disease is associated with this finding?
altered shape
1:1 length to width ratio
COPD
chronically overinflated lungs so rib cage remains partially expanded
what are normal percussion findings during respiratory assessment?
anterior chest:
resonance to 2nd ICS on left to 4th ICS on right
what are abnormal percussion findings during respiratory assessment?
dullness:
tumors
fluid
pleural effusion
pneumonia
pulmonary edema
what changes occur with an older client’s blood pressure?
increased systolic
which patient should you see first:
one with hypertension
one who is leaving for surgery
or one who has chest pain?
chest pain
which can AP perform for you:
palpate pedal pulses
performed health history
put a patient on oxygen
or document intake/output?
document intake/output
when auscultating the heart and listening for high pitched sounds, what part of the stethoscope do you use?
diaphragm
if you gave a client medications then come back in 30 min to see how they are,
what part of nursing process is this?
evaluation
when BP drops with positional changes,
what is that called and what nursing diagnosis can be used?
orthostatic hypotension
risk for falls
risk for injury
what is occurring during lub heart sound?
AV valve closure
what occurs during dub heart sound?
aortic and pulmonic valves closing
bubbling popping rattling lung sounds are called?
crackles
high pitched musical squeaking lung sound are called?
wheezes
how do you evaluate a patient to see if breathing medication worked?
listen to lungs to see if wheezing improved
which patient do you see first:
one waiting for discharge
someone screaming for morphine
or a patient with dyspnea?
patient with dyspnea
why are older adults at a higher risk for pneumonia?
lungs are rigid and harder to inflate
what step is first in respiratory assessment?
inspection:
look for scars
assess respiratory rate
rhythm
depth
symmetry of chest movement
barrel chest
spinal deformities
accessory muscle use
intact skin
when auscultating the lungs, how long should you listen in each spot?
one full ventilation - inhale / exhale
what is the correct direction of lung sound auscultation?
side to side to compare
how do you determine if there is a pulse deficit?
one nurse counts the radial pulse while one nurse counts the apical pulse for one minute then subtract the difference
who is at the greatest risk for developing pneumonia after having a procedure:
a 32yo who just had abdominal surgery
an 82yo with syncope
an 18yo refusing to ambulate
or a 45yr with COPD
45yo with COPD -
encourage patient to get pneumovax as it is very difficult to recover from pneumonia with COPD
which pulse is never assessed bilaterally at the same time?
carotid
will cut off brain blood flow
post-bp patient needs to do what to prevent pneumonia?
sit up in chair for each mail
oral care BID
incentive spirometer - 5-10 hourly while awake
cough and deep breathe
which patients are the most susceptible to environmental pollution?
patients with asthma
how can patients prevent COPD and what is the number 1 cause of this disease?
stop smoking
what is the cause of high pitched monophonic crowing sound and patient has croup, how high of priority is this patient?
stridor
number 1 - caused by an obstruction
where is erb’s point?
3rd ICS, left of the sternum
when you hear S1/S2 but the heart rate is 120 bpm, what is this called?
sinus tachycardia
what is the term for short high pitched popping sounds over the lung bases that usually disappear after a few deep breaths and coughs?
fine crackles - alveoli deflated right after waking up
primary pacemaker of the heart is?
SA Node
what is the term for the low-pitched snoring sound heard over the bases?
Rhonchi
if you can’t palpate a pulse, what should you use?
doppler
where does gas exchange occur?
alveoli
what is eupnea?
normal breathing
if patient had RR of 30, are they in respiratory distress?
yes
how do you calculate cardiac output?
co = sv x hr
what causes a soft low pitched rushing sound?
bruit
what are 4 findings with a COPD patient?
barreled chest
chronic productive cough
tachypnea
clubbing
fatigue
accessory muscle use
prolonged expiration
SpO2 88-92% or lower
when taking a manual BP, what artery are you listening to?
brachial
where do you assess for a popliteal pulse?
behind the knee
what is a normal CRT?
< 2 seconds
what is the correct order of techniques for a cardiac assessment?
inspection
palpation
auscultation
(dont have to percuss heart)
