Respiratory & Cardiac PrepU Health Assessment

in palpating the chest of a client, a nurse feels a U-shaped indentation on the superior border of the manubrium. the nurse recognizes this landmark as which of the following?

suprasternal notch

which of the following statements most accurately describes preload?

the amount of blood in the ventricles at the end of diastole

the nurse is assessing a client with a cardiac condition who complains of fatigue & nocturnia. the nurse should recognize what implication of this statement?

the client may be experiencing symptoms of heart failure.

a client has sustained a brain stem injury & is being treated in the intensive care unit. what would the nurse need to consider when assessing this client's respiratory status?

the client will have a loss of involuntary respiratory control.

a nurse is preparing a class for a local community group on coronary heart disease. which of the following recommendations would the nurse include as appropriate for reducing a person's risk? (select all that apply.)

use relaxation techniques to manage stress, walk for atleast 30 minutes/day, & eats foods low in sodium.

a respiratory pattern that gradually becomes faster & deeper than normal, then slower, alternating with periods of apnea is known as which respiratory pattern?

Cheyne-Strokes

during the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. how should the nurse document these sounds?

coarse crackles

the client has been admitted through the emergency department with chronic bronchitis, has elevated CO2 levels, & has been placed in O2. what priority assessment would the nurse include?

evaluate changes in respiratory pattern & rate.

the nurse is preparing to assess a client's apical impulse. the nurse should palpate at which location?

fifth intercoastal space, left midclavicular line

a client with dehydration or volume depletion has barely visible neck veins, even when lying flat. these are described as what?

flat neck veins

which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

forward position

which subjective finding in a client with tuberculosis should a nurse recognize as an indication of the onset of pleurisy?

knife-like pain that worsens on inspiration

while conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. this finding is most likely a manifestation of which problem?

left-sided heart failure

a nurse is palpating the sternum of a client. if the client is healthy, which of the following would characterize his costal angle?

less than 90 degrees

the clavicles extend from the acromion of the scapula to the part of the sternum termed the

manubrium.

a 25-year-old optical technician comes to the clinic for evaluation of fatigue. as part of the physical examination, the nurse listens to her heart & hears a murmur only at the cardiac apex. which valve is most likely to be involved based on the location of the murmur?

mitral

while assessing an adult client, the nurse detects opening snaps early in diastole during auscultation of the heart. the nurse should refer the client to a physician because this is usually indicative of

mitral valve stenosis.

a group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. the students are correct in identifying it as which of the following?

myocardium

a nurse is working with a client who recently suffered a heart attack. as a result, the client has experienced the death of the muscle tissues that make up the thickest layer of the heart. this layer of muscle is known as which of the following?

myocardium

a nurse performs an initial health history on a client admitted for new onset of chest pain. which data is considered subjective for the cardiovascular system?

no current medications or treatments

a nurse in the operating room has a client who just underwent gastric bypass surgery & weighs 243 kilograms (534.6 pounds). upon extubation, the client's oxygen saturation drops to 84% & the client has difficulty catching her breath. what could be causing these problems?

obesity, which can limit chest wall expansion & compromise breathing

a nurse is assessing a client for possible dehydration. which of the following should the nurse do?

observe for a decrease in jugular venous pressure

a nurse observes a client sitting in the tripod position. what is an appropriate action by the nurse in response to this observation?

observe for the use of accessory muscles

when auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

one deep inspiration & expiration through the open mouth

all of the following statements are descriptive of events during the diastole portion of the cardiac cycle except:

opening of the mitral valve

a client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 & receives 4 mg of morphine. a nurse on the orthopedic unit enters the client's room & finds that the client has a respiratory rate of 7 breaths/min. the client is groggy & hard to arouse. what could be contributing to the client's findings?

opiates, which may cause hypoventilation

a client complains of difficulty sleeping, stating he has to sit up with the help of several pillows & cannot breathe when lying flat. this client has a condition known as what?

orthopnea

a nursing student is reviewing the electrical conduction of the heart. the student is correct in identifying the sinoatrial node of the heart as which of the following?

pacemaker

a nurse experiences difficulty differentiating S1 from S2 when auscultating a client's heart sounds. what is an appropriate action by the nurse?

palpate the carotid pulse simultaneously

the nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique?

palpating carotid pulses simultaneously.

a triage nurse is working in the emergency department of a busy hospital. four patients have recently been admitted. patient A has an arrhythmia diagnosed as atrial fibrillation; patient B is in chronic congestive heart failure; patient C is assessed and found to have a probable pulmonary embolism; patient D complains of chest pain relieved by nitroglycerin and rest. which patient would be the nurse's highest priority?

patient C

a client is diagnosed with pulmonary edema. the nurse would most likely assess the sputum color as which of the following?

pink

a client is diagnosed with pulmonary edema, & the nurse is performing a rapid assessment prior to treatment. the nurse would be most concerned about what assessment finding related to the client's sputum?

pink & frothy

the nurse is assessing a 79-year-old client's posterior thorax during a focused respiratory assessment. the nurse should attribute what assessment finding to age-related changes?

slight kyphosis

the nurse is assessing the apices of the client's lungs. the nurse should locate them at which position?

slightly above the clavicle

when assessing whispered pectoriloquy, what would the nurse instruct the client to do?

softly repeat the words 'one-two-three'.

a client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. what change in egophony should the nurse expect to find in the left lower lobe?

sound is louder & sounds like "A"

a 17-year-old high school senior presents to the clinic in acute respiratory distress. between shallow breaths he states he was at home finishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. he denies any recent traumas or illnesses. his past medical history is unremarkable. he doesn't smoke, but drinks several beers on the weekend. he has tried marijuana several times but denies any other illegal drugs. he is an honour student and on the basketball team. his parents are both in good health. he denies any recent weight gain, weight loss, fever, or night sweats. examination shows a tall, thin young man in obvious distress. he is diaphoretic and breathing at a rate of 35 breaths per minute. auscultation reveals no breath sounds on the right side of his superior chest wall. on percussion he is hyperresonant over the right upper lobe. with palpation he has absent fremitus over the right upper lobe. what disorder of the thorax or lung best describes his symptoms?

spontaneous pneumothorax

when preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start?

sternal angle

where are the heart & great vessels located in the human body?

the mediastinum, between the lungs & above the diaphragm

the nurse assesses shallow respirations of 28 breaths/minute in a client with pleurisy. the nurse interprets this finding as indicating which of the following?

the pattern is expected with this condition

which observation confirms to the nurse that the client is experiencing a normal inspiration?

the thoracic cavity enlarges.

a client has sustained a brain-stem injury. which of the following would the nurse need to keep in mind about this client's respiratory effort?

there is loss of involuntary respiratory control.

the nurse is auscultating the heart sounds of an adult client. to auscultate Erb point, the nurse should place the stethoscope at the

third to fifth intercostal space at the right sternal border.

the nurse auscultates very loud, high-pitched lung sounds that are equal in length over a client's anterior chest. which area did the nurse most likely hear these sounds?

trachea

the nurse is conducting a health history with a female client who reports upper back & jaw pain. in order to assess the client's risk for a cardiac event, which question should the nurse ask first?

"do you have any pain or discomfort in your chest?"

while assessing the health of a client's respiratory system, the nurse is palpating for fremitus. what instruction should the nurse provide to the client during this component of assessment?

"please say the number 'ninety-nine' for me."

a client tells the nurse he is very worried that he will have a heart attack because he recently noticed he is having fluttering in his chest. the client also reports his heart feels like it sometimes "skips a beat." which response best addresses the client's symptoms?

"this problem can depend on how you respond when you notice it."

the nurse assesses a client's carotid pulse & finds it to be of normal amplitude. how would the nurse document this finding in the client's electronic medical record?

2+

the nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. which location should the nurse assess next?

2nd intercostal space left sternal border

the nurse places the stethoscope on the 3rd intercostal space at the left sternal border. which area is the nurse auscultating for heart sounds?

Erb point

when describing the cardiac cycle to a group of students, the instructor correlates heart sounds with events of the cycle. which heart sound would the instructor explain as being associated with systole?

S1

a nurse is receiving report from the night shift about four clients. which client would the nurse see first?

a 64-year-old man with COPD who is short of breath & has a respiratory rate of 32 breaths/min

the nurse positions the client for auscultation of heart sounds. what does the nurse do first?

clean the stethoscope

when auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. how should the nurse describe S2?

accentuated

the nurse is determining the number of annual influenza inoculations that will need to be provided to a group of community members. which members would benefit from receiving this vaccination? (select all that apply.)

adult patient caring for children under age 5, older adult attending adult day care, & adult patient with chronic obstructive pulmonary disease

an adult client visits the clinic & tells the nurse that she feels chest pain down her left arm. the nurse should refer the client to a physician for possible

angina.

when auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. the nurse determines that this finding is consistent with the closure of which heart valves?

aortic & pulmonic

the apex of each lung is located at the

area slightly above the clavicle.

a nurse recognizes that the second heart sound, S2, is produced by which cardiac action?

closure of the semilunar valves

a male client comes to the clinic complaining of a persistent cough. further questioning reveals that he was just recently diagnosed with hypertension. which of the following would the nurse do next?

ask about any medications being used for hypertension.

the nurse is assessing a client's respiratory rate & rhythm during the beginning of a shift. the client's rate is 29 breaths per minute. how should the nurse respond to this assessment finding?

ask the client if she has recently exerted herself.

the nurse is auscultating a client's breath sounds. what should the nurse do first after hearing an unusual sound?

ask the client to cough

how should a nurse assess a client for pulse rate deficit?

assess for a difference between the apical & radial pulse

a 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. she states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. she denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. she has had no surgeries. her mother has allergies and eczema; her father has high blood pressure. she is an only child. she denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. she is a junior in finance at a local university and has recently started a job as a bartender in town. on examination she is in no acute distress. temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. head, eyes, ears, nose, and throat examinations are essentially normal. inspection of her anterior and posterior chest shows no abnormalities. on auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. percussion reveals resonant lungs. which disorder of the thorax or lung does this presentation best describe?

asthma

the client asks the nurse what the small P wave on her ECG indicates. what would the nurse answer?

atrial depolarization

a nurse auscultates a client's heart rate & rhythms & finds the rhythm to be irregular. what would the nurse do next?

auscultate for a pulse rate deficit.

the nurse is preparing to percuss a patient's anterior chest area. which approach will the nurse use for this assessment?

begin above the right clavicle & percuss each section comparing the right chest with the left chest.

a nurse auscultates a client's hear sounds & obtains a rate of 56 beats per minute. how should this rate be documented by the nurse?

bradycardia

which type of breath sounds should a nurse anticipate on auscultation of the right lower lobe in a client with right lower lobe pneumonia?

bronchial

while auscultating a client's trachea, the nurse hears a high, harsh sound with short inspiration & long expiration. how would the nurse document this finding?

bronchial breath sounds

when crackles, wheezes, or rhonchi clear with a cough, which of the following is likely an etiology?

bronchitis

which of the following statements relating to assessment of the lungs & thorax is most accurate?

bronchitis is characterized by excess mucus production & chronic cough.

the nurse hears high-pitched swooshing sounds over the carotid artery on the right side. what is this sound indicative of?

bruits

which of the following muscles is primarily responsible for thoracic cavity enlargement?

diaphragm

a student is asked to define the continuous rhythmic movement of blood during contraction & relaxation of the heart. this best describes which of the following?

cardiac cycle

a nurse is assessing a client for the presence of stenosis in the carotid arteries. which of the following should the nurse do?

check for pulse inequality between right & left carotid arteries

the nurse assesses an adult client & observes that the client's breath pattern is very labored & noisy, with occasional coughing. the nurse should refer the client to a physician for possible

chronic bronchitis.

a 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. although symptoms have occasionally worsened with a cold, they have stayed about the same. the cough has occasional mucus drainage but never any blood. he denies any chest pain. he has had no weight gain, weight loss, fever, or night sweats. his past medical history is significant for high blood pressure and arthritis. he has smoked two packs a day for the past 45 years. he drinks occasionally but denies any illegal drug use. he is married with two children. he denies any foreign travel. his father died of a heart attack and his mother died of Alzheimer's disease. examination reveals a man looking slightly older than his stated age. his blood pressure is 130/80 and his pulse is 88. he is breathing comfortably with respirations of 12. his head, eyes, ears, nose, and throat examinations are unremarkable. his cardiac examination is normal. on examination of his chest, the diameter seems enlarged. breath sounds are decreased throughout all lobes. rhonchi are heard over all lung fields. there is no area of dullness and no increased or decreased fremitus. what thorax or lung disorder is most likely causing his symptoms?

chronic obstructive pulmonary disease (COPD)

the nurse has assessed the respiratory pattern of an adult client. the nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. the nurse should contact the client's physician because this type of respiratory pattern usually indicates

diabetic ketoacidosis

the nurse is reviewing the client's health history & notes he has pectus excavatum. the nurse would assess the client for what?

funnel chest

a grandmother brings her 13-year-old grandson for evaluation. she noticed last week when he took off his shirt that his breastbone seemed collapsed. he seems embarrassed and says that it has been that way for awhile. he states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. he denies any shortness of breath, chest pain, or lightheadedness on exertion. his past medical history is unremarkable. he is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. his mother died several years ago in a car accident. he states that he does not smoke and has never touched alcohol. examination shows a teenage boy appearing his stated age. visual examination of his chest reveals that the lower portion of the sternum is depressed. auscultation of the lungs and heart is unremarkable. what disorder of the thorax best describes these findings?

funnel chest (pectus excavatum)

how does the nurse differentiate a pleural friction rub from a pericardial friction rub?

have the client hold his or her breath; if the rub persists, it is pericardial

during the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following?

heart attacks in his father & siblings

a client has sought care with complaints of increasing swelling in her feet & ankles, & the nurse's assessment confirms the presence of bilateral edema. the nurse's subsequent assessment should focus on the signs & symptoms of what health problem?

heart failure

a client presents to the health care facility with sudden onset of shortness of breath, inability to lie flat, & a deep, wet cough. a nurse observes a respiratory rate of 18 breaths per minute, use of accessory muscles to breathe, & inability to cough up secretions. which nursing diagnosis can be confirmed with this data?

ineffective airway clearance

a nurse is caring for a client diagnosed with cystic fibrosis. the client has a history of repeated hospital admissions for complications of his disease & receives daily treatments to mobilize the secretions. when planning the care of this client, what nursing diagnosis is most appropriate?

ineffective airway clearance related to respiratory secretions

a client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. the nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. a grade 3 systolic murmur is auscultated. which nursing diagnosis can the nurse confirm based on this data?

ineffective tissue perfusion

a nurse cares for a client who suffered a myocardial infarction two (2) days ago. a high-pitched, scratchy, scraping sound is heard that increase with exhalation & when the client leans forward. the nurse recognizes this sound as a result of what process occurring within the pericardium?

inflammation of the pericardial sac

which technique would be most appropriate to use when examining the jugular venous pulse?

inspect the suprasternal notch or around the clavicles.

a nurse auscultates a client's lungs & hears fine crackles. what is an appropriate action by the nurse?

instruct the client to cough forcefully

which is true of a third heart sound (S3)?

it is caused by rapid deceleration of blood against the ventricular wall.

the nurse auscultates the base of the lungs to assess for what reason?

it is where fluid occurs with pulmonary edema.

a 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. she says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. she denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. her past medical history includes type 2 diabetes for 5 years and high cholesterol level. she takes an oral medication for both diseases. she has had no surgeries. she denies tobacco, alcohol, or drug use. her mother has diabetes and high blood pressure. her father passed away from colon cancer. examination reveals a middle-aged woman appearing her stated age. she looks ill and her temperature is elevated at 101 degrees Fahrenheit. her blood pressure and pulse are unremarkable. her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. on auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. there is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. what disorder of the thorax or lung best describes her symptoms?

pneumonia

when percussing the posterior lung fields, which of the following findings is expected?

resonance over all lung fields

a client has engorged jugular veins. what should this finding suggest to the nurse?

right atrial pressure

while completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. which of the following potential problems should the nurse further investigate?

shortness of breath

a nurse is assessing a client with acute asthma. which adventitious breath sound should the nurse expect to hear in this client?

sibilant wheezes heard primarily during expiration but may also be heard on inspiration

a nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. the nurse should be aware that the electrical signal originates in what location?

sinoatrial node

which of the following occurs in respiratory distress?

skin between the ribs moves inward with inspiration.