Nursing Test 3

Erb's point

3rd ICS left sternal border

The nurse receives a client assignment. Which client should the nurse see first?

A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 16 bpm

The acute care nurse is assessing a newly admitted client's abdomen. Which finding would indicate the need to contact the health care provider?

Auscultation of a bruit

The nurse is performing a respiratory assessment for a client and hears a high-pitched, harsh "blowing" sound, with sound on expiration being longer than inspiration. How will the nurse document this finding?

Bronchial breath sounds

crackles

Bubbling, crackling, popping Low- to high-pitched, discontinuous sounds Auscultated during inspiration and expiration Opening of deflated small airways and alveoli; air passing through fluid in the airways

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

Crackles

S2

DUB pulmonic and aortic valves bottom

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

Each lub-dub is one beat.

stridor

Harsh, loud, high-pitched Auscultated on inspiration Narrowing of upper airway (larynx or trachea); presence of foreign body in airway

S1

LUB tricuspid and mitral valves top

wheeze

Musical or squeaking High-pitched, continuous sounds Auscultated during inspiration and expiration Air passing through narrowed airways

A nurse is assessing several clients with respiratory problems. Which findings would the nurse document as normal, age-related thorax and lung variations? Select all that apply.

Newborns and children using abdominal muscles during respiration Older adults having an increased anterior-posterior (AP) chest diameter Older adults having an increase in the dorsal spinal curve (kyphosis)

The nurse is palpating a client's precordium. Which result is an expected clinical finding?

Palpable pulsation over the mitral area

A client has been diagnosed with peripheral vascular disease of the lower extremities. What will the nurse assess to accurately chart the circulation status in the client's legs? Select all that apply.

Pitting edema Pedal pulses Skin temperature of feet Capillary refill time

A nurse is preparing to assess the thorax and abdomen of a client using the head-to-toe physical assessment method. Place the assessment techniques in the order in which they should be performed. All options must be used.

Position the client supine and drape appropriately. Inspect the skin of thorax and abdomen. Palpate the thorax. Auscultate the thorax. Auscultate the abdomen. Palpate the abdomen.

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

Presence of sputum in the trachea

pleural friction rub

Rubbing or grating Loudest over lower lateral anterior surface Auscultated during inspiration and expiration Inflamed pleura rubbing against chest wall

Third ICS (Erb's point)

S1 and S2 can be heard equally

A nurse assesses breath sounds for clients presenting at a local clinic with difficulty breathing. Which sounds would the nurse document as normal? Select all that apply.

Soft, low-pitched, whispering sounds heard over most of the lung fields Medium-pitched, medium-intensity blowing sounds, auscultated over the first and second interspaces anteriorly and the scapula posteriorly Blowing, hollow sounds auscultated over the larynx and trachea

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which signs are observed? Select all that apply.

The client is demonstrates restlessness. The client's capillary refill is assessed at 4 seconds. The client has uneven movements of the chest with respirations. The client has flaring nostrils

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply.

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

The nurse should use the bell of the stethoscope during auscultation of:

a client's heart murmur.

bruits

abnormal "swishing" sounds heard over a blood vessel

adventitious breath sounds

abnormal breath sound heard over the lungs

S3 sounds

abnormal in patients older than 40 increased atrial pressure extra DUB sound quiet low pitched hard to hear

precordium

anterior surface of the chest wall overlying the heart and its related structures

higher GI bleeding

black tarry stool

While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these?

bronchovesicular

lower GI bleeding

coffee ground stool

The nurse is providing care for a male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. What should the nurse document as being present?

crackles

tricuspid valve

fourth ICS left sternal border

pulmonic valve

left sternal border second intercostal space

hypoactive bowel sounds

less than 15 per/min constipation/anesthesia

midclavicular line

mitral apical area apex of heart where you palpate point of maximal impulse

hyperactive bowel sounds

more than 30 per/min cliff IBS

S4 sounds

non compliant ventricle bc of hypertension hypertrophy or fibrosis extra LUB sounds before S1

bronchovesicular breath sounds

normal breath sounds heard over the mainstem bronchus; they are moderate blowing sounds, with inspiration equal to expiration

vesicular breath sounds

normal sound of respirations heard on auscultation over peripheral lung areas

bowel sounds

occur every 5-15 seconds 15-30 per minute

auscultation of abdomen

right lower quadrant 1min-right upper quadrant 1min- left upper quadrant 1 min- left lower quadrant 1min- right lower quadrant again 1min

aortic valve

right second intercostal space sternal border

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

slightly contoured chest with no sternal depression anteroposterior diameter of the chest less than the transverse diameter bronchial, vesicular, and bronchovesicular breath sounds

bronchial breath sounds

those heard over the larynx and trachea are high-pitched, harsh "blowing" sounds, with sound on expiration being longer than inspiration

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

wheezes