Exam 3 reviewsss

What are the five areas to auscultate when listening to the heart?

- Aortic, Pulmonic, Erb's point, Tricuspid, Mitral

A young adult patient reports difficulty in breathing. Upon inspection, the patient is cyanotic, using accessory neck muscles to breathe, and audibly wheezing. Palpation reveals decreased tactile fremitus with hyperresonant sounds on percussion. Normal breath sounds are distant and hard to hear because of wheezing. The nurse suspects further testing will lead to which diagnosis? A.Asthma B.Bronchitis C.Pneumonia D.Atelectasis

a

Which physiologic mechanism causes the first heart sound? A.Closing of the mitral valve B.Filling of the ventricle C.Closing of the aortic valve D.Closing of the pulmonic valve

a

The nurse knows closure of the ....... valves indicates s1 sound (best heard at apex), and closure of the ........indicate s2 sound (heard best at base of heart).

bicuspid/tricuspid pulmonic and aortic semilunar valves

An audible whooshing sound to an artery that indicated turbulent blood flow is called a ...

bruit

A client Is exhibiting progressively deeper and faster respirations with eventual periods of apnea. These respirations are known as.

- Cheyne-Stokes • Biot's respirations - shot/fast with periods of apnea • Hyperventilation - breathing off too much CO2

When auscultating extra heart sounds, s3 can also be referred to a ...... gallop, and s4 can be referred to a ........ gallop

semilunar atrioventricular

What should be heard over normal lung fields upon percussion?

- Resonant (respiratory regular resonant) • Hyperresonance: is found when too much air is present such as in emphysema or pneumothorax • Dull: signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. • Tympany: large air collection, as with a pneumothorax

The nurse is educating the students on the difference of the right and left lobes. What are those differences?

- Right: shorter and wider, contains three lobes - Left: longer and narrower, contains two lobes

A nurse is rounding on a male client when he begins to c/o shortness of breath. What should the nurse do next?

- assess pulse oximetry and lung sounds • not put oxygen because if the pulse ox and lung sounds are normal they could just be having an anxiety attack.

A palpable vibration to an artery is called...

thrill

The OB nurses are educating the healthy pregnant female client made by the client confirms understanding of the teaching?

- "My BP will decrease during pregnancy." • Blood volume increases, increasing HR 10-20 beats more • Decreased BP results due to vasodilation, lowest at 2nd trimester and rises after.

A 50 y/o male client is admitted to ER with SOB. Upon assessment he is leaning forward and using of accessory muscles of breath. He presents with a barrel chest and above 180-degree angle to nail beds noted. Upon assessment of his lungs wheezing was auscultated to anterior and posterior lobes. What S/S concern you about this client? What may ultimately be his medical diagnosis?

- COPD (emphysema)

When assessing a client with heart failure popping sounds are auscultated to the lower lobes. How may the nurse chart this finding?

- Crackles • Crackles - popping; fluid in alveoli - HF, pneumonia • Wheezing - musical sounding: constricted bronchioles - COPD, asthma • Diminished - decreased sounds: collapsed alveoli - post op, bed ridden • Rub - grating sound: increased fluid in pleural cavity - infection, trauma

Which of the following S/S may be assessed on a client with right sided heart failure?

- Jugular venous distention and peripheral edema

When assessing a newborn infant, which finding is the most concerning?

- Nasal flaring • Infant breathes through nose rather than mouth and is an obligate nose breather until 3 months • Irregular breathing pattern is noted, brief periods of apnea less than 10 or 15 seconds are common, therefore it is important to count respirations for a full minute.

Which observations would the nurse expect in a patient with chronic obstruction pulmonary disease (COPD)? Select all that apply. A.The neck muscles appear to be hypertrophied from overwork B.The spinous processes appear as if they are in a straight line C.There are no major changes in the color of the patient's skin D.The patient leans forward with the arms against the knees E.The anteroposterior and transverse diameter are both equal

a, d, e

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? A.Crackles B.Wheezes C.Rhonchus D.Pleural friction rub

b

During auscultation of the heart, where would the nurse expect the first heart sound (S1) to be the loudest? A.Base of the heart B.Apex of the heart C.Left lateral border D.Right lateral border

b

In which location would the nurse auscultate the highest point of the lung on the anterior side of the chest? A.Seventh cervical vertebra B.3 to 4 cm above the clavicle C.Twelfth thoracic vertebra D.Six rib in the midclavicular line

b

The nurse auscultates the patient's respirations and notes breath sounds similar to opening Velcro. Which term would the nurse use to document this finding? A.Fine crackles B.Coarse crackles C.Pleural friction rub D.High-pitched wheeze

b

The nurse instructs a student nurse to palpate the patient's carotid artery. Which action made by the student nurse needs correction? A.Having the patient sit during the exam B.Palpating both carotid arteries at once C.Refraining from excess vagal stimulation D.Not compressing the carotid sinuses

b

Which assessment finding may be present in a patient with atherosclerosis? A.Low-pitched rumbling B.Presence of bruit sound C.Weak contraction of the ventricles D.Unilateral distention of the external jugular veins

b

Which landmark is correct for the nurse to use when auscultating the mitral valve? A.Left fifth intercostal space, midaxillary line B.Left fifth intercostal space, midclavicular line C.Left second intercostal space, sternal border D.Left fifth intercostal space, sternal border

b

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? A.Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. B. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. C.Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. D.Assist the client in assuming a position of comfort and perform postural drainage.

c

When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. Which valve does this sound reflect? A.Aortic B.Mitral C.Pulmonic D.Tricuspid

c

Which assessment finding indicates abnormally elevated pressures in the right side of the heart? A.Pulmonary congestion B.Pulmonary hypertension C.Distended neck veins and abdomen D.Systolic blood pressure higher than the diastolic pressure

c

A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is for which reason? A.Spasm of the bronchi that traps the air B.Increase in the vital capacity of the lungs C.Too rapid expulsion of air from the bronchioles D.Difficulty in expelling the air trapped in the alveoli

d

The patient with pathologic S 3 heart sound has which condition? A.A stenotic heart valve B.Coronary artery disease C.Vigorous atrial contraction D.Decreased compliance of the ventricles

d

Which data regarding chest palpation findings is accurate? Data/condition/intensity of vibrations 1. pleural effusion/increased vibrations 2. pneumonia/decreased vibrations 3. pneumothorax/absence of vibrations 4. lung hyperinflation/ absence of vibrations

data 3