What type of assessment is needed for a patient having SOB? - Answers Focused respiratory
assessment
What are some things you would assess during a focused respiratory assessment? - Answers
Respiratory rate, O2 sat, pattern, breath sounds, nasal flaring, chest expansion
List 3 adventitious breath sounds - Answers Crackles, rhonchi, and wheezing
List nursing interventions for crackles - Answers Diuretics, elevate HOB 90 degrees
List nursing interventions for rhonchi - Answers Encourage cough, increase fluids, avoid dairy
List nursing interventions for wheezing - Answers bronchodilators, anti-inflammatories
What adventitious breath sound CAN be cleared by coughing? - Answers Rhonchi
C/o leg pain, errythema, warmth, and swelling indicates? - Answers Deep vein thrombosis DVT
What medications are DVTs treated with? - Answers coumadin and heparin
How does the nurse assess vocal (tactile) fremitus? - Answers "99"
Define atelectasis - Answers collapse of the alveoli in the bases of the lungs
List interventions to prevent atelectasis - Answers TCDB, incentive spirometer, CPT, elevate
HOB, encourage fluids
Define pneumothorax - Answers collapse of whole lung
How is pneumothorax treated? - Answers chest tube
List symptoms of cardiovascular disease - Answers cyanosis, arrhythmia, edema, prolonged
cap. refill, angina, SOB; dyspnea, fatigue, thready pulse
How does a nurse assess chest excursion? - Answers place thumbs on back, instruct to "take a
deep breath," thumbs should move apart about 5"
What could be indicative of thumbs not moving about 5" on each side during an assessment of
chest excursion? - Answers a collapsed lung
What is the nurse's action when finding an irregular-shaped pupil in one eye? - Answers Ask,
"were you born with this?"
What would patient data of "smokes cigarettes" indicate? - Answers Need for a focused
assessment
What questions would a nurse ask a smoker? - Answers How much? how long? What kind?
, Cough? Productive? Color?
Name abnormal heart sounds - Answers Murmur, rub, gallop, S3, S4
What is a common abnormal heart sound after open heart surgery? - Answers Rub
Name the characteristics that are noted when assessing a radial pulse. - Answers Rate, rhythm,
strength, equality, and elasticity.
Where is the FIRST location that the nurse would place her stethoscope to auscultate heart
valves? - Answers Right second intercostal space
Where is the SECOND location that the nurse would place her stethoscope to auscultate heart
valves? - Answers Left second intercostal space
Where is the THIRD location that the nurse would place her stethoscope to auscultate heart
valves? - Answers Left third intercostal space
Where is the FOURTH location that the nurse would place her stethoscope to auscultate heart
valves? - Answers Left fourth intercostal space
Where is the FIFTH location that the nurse would place her stethoscope to auscultate heart
valves? - Answers Left fifth intercostal space midclavicular line
What is the name of the FIRST valve auscultated during a cardiovascular assessment? -
Answers Aortic
What is the name of the SECOND valve auscultated during a cardiovascular assessment? -
Answers Pulmonic
What is the name of the THIRD valve auscultated during a cardiovascular assessment? -
Answers Erb's point
What is ANOTHER name for the THIRD valve auscultated during a cardiovascular assessment? -
Answers Second pulmonic
What is the name of the FOURTH valve auscultated during a cardiovascular assessment? -
Answers Tricuspid
What is the name of the FIFTH valve auscultated during a cardiovascular assessment? -
Answers Mitral
What are OTHER common names of the FIFTH valve auscultated during a cardiovascular
assessment? - Answers Apex and point of maximal impulse (PMI)
What causes the S1 heart sound? - Answers Closing of the tricuspid valve
What causes the S2 heart sound? - Answers Closing of the mitral valve