NURS 612 Exam 2 with Detailed Questions
and Correct Verified Answers | Advanced
Nursing Study Guide |100% Verified and
Updated |Latest Exam |Brand new
Version!!!!
Inspect the chest
ANSWER:
without clothes on; 1st assess shape and size; 2nd check for
symmetry; 3rd thoracic landmarks; 4th color of skin; 5th check for
supernumerary nipples; 6th superficial venous patterns; and 7th
observe for rib prominence
Thoracic landmarks
ANSWER:
midline trachea, costal angle, angle of ribs, intercostal spaces,
suprasternal notch
Symmetry of chest
ANSWER:
thoracic expansion at costal angle, w/o use of accessory muscles
Hx questions for cc of resp issue
ANSWER:
What is the nature of your cough?; Do you produce any sputum?; Is
your cough related to activity?; What position are you most
,comfortable in?; How many pillows do you sleep with at night?; Is your
SOB related to activity?
Normal respirations
ANSWER:
rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt should
breathe easily, regularly w/o apparent distress; pattern should be
even, not too shallow or too deep
Hypopnea
ANSWER:
term for abnormally shallow respirations
Tachypnea
ANSWER:
term for resp rate greater than 20, but consistent and may occur
during hyperventilation; often a symptom of pain
Bradypnea
ANSWER:
term for resp rate less than 12; may indicate neurologic or electrolyte
disturbances, infection, or conscious response to protect against the
pain of pleurisy or other irritative pneumonia. Can also be 2/2 level of
cardio fitness
Hyperventilation
ANSWER:
term for fast and deep, heavy respirations, can be caused by exercise,
anxiety, and CNS and metabolic diseases
Hyperpnea
ANSWER:
term for abnormally deep respirations
,Kussmaul respirations
ANSWER:
deep and mostly rapid respirations, used to describe resp effort of
metabolic acidosis
Cheyne stokes respirations
ANSWER:
regular breathing with intervals of apnea by crescendo decrescendo
breathing; can be seen in sleeping pts, but mostly pts who are very ill,
esp with brain damage
Biot respirations
ANSWER:
irregular breathing that varies in depth and is interrupted irregularly
by intervals of apnea; associated with severe and persistent
increased intracranial pressure, resp compromise from drug
poisoning, or brain damage at the medulla and generally equals poor
prognosis
Peripheral areas related to respiratory assessment
ANSWER:
observe the lips and nails for cyanosis or pallor; lips for pursing;
fingers for clubbing; and alae nasi for flaring
Pleural friction rub
ANSWER:
dry, rubbing, or grating sound; palpable, coarse, grating vibration;
usually on inspiration; caused by inflammation of the pleural surfaces;
think feel of leather rubbing on leather
Thoracic expansion
ANSWER:
, stand behind patient and place thumbs along spinal process at level
of 10th rib, with palms lightly in contact with the posterolateral
surfaces; watch the thumbs during quiet and deep breathing; loss of
symmetry = problem on either 1 or both sides.
Crepitus
ANSWER:
crackly/crinkly sensation that can be palpated and heard, a gentle
bubbly feeling; indicates air in the subcutaneous tissue from a rupture
somewhere in the resp system, or infection with gas producing
organism
Palpating the chest and trachea
ANSWER:
palpate the throracic muscles and skeleton; feeling for pulsations,
areas of tenderness, bulges, depressions, masses, and unusual
movement
Tactile fremitus
ANSWER:
palpable vibration of the chest wall that results from speech or other
verbalizations. best felt posteriorly and laterally at the level of the
bifurcation of the bronchi; have patient say "99" while you palpate
with palmer surface of fingers or ulner aspect of the hand; use firm,
light touch
Abnormal tactile fremitus
ANSWER:
decreased of absent fremitus may be caused by excess air in lungs or
may indicate emphysema, pleural thickening, or effusion, massive
pulm edema, or bronchial obstruction. Increased fremitus often
coarser or rougher in feel, caused by presence of fluids or solid mass
within the lungs.
and Correct Verified Answers | Advanced
Nursing Study Guide |100% Verified and
Updated |Latest Exam |Brand new
Version!!!!
Inspect the chest
ANSWER:
without clothes on; 1st assess shape and size; 2nd check for
symmetry; 3rd thoracic landmarks; 4th color of skin; 5th check for
supernumerary nipples; 6th superficial venous patterns; and 7th
observe for rib prominence
Thoracic landmarks
ANSWER:
midline trachea, costal angle, angle of ribs, intercostal spaces,
suprasternal notch
Symmetry of chest
ANSWER:
thoracic expansion at costal angle, w/o use of accessory muscles
Hx questions for cc of resp issue
ANSWER:
What is the nature of your cough?; Do you produce any sputum?; Is
your cough related to activity?; What position are you most
,comfortable in?; How many pillows do you sleep with at night?; Is your
SOB related to activity?
Normal respirations
ANSWER:
rate between 12 to 20/min; ratio of resp to heart beats= 1:4; pt should
breathe easily, regularly w/o apparent distress; pattern should be
even, not too shallow or too deep
Hypopnea
ANSWER:
term for abnormally shallow respirations
Tachypnea
ANSWER:
term for resp rate greater than 20, but consistent and may occur
during hyperventilation; often a symptom of pain
Bradypnea
ANSWER:
term for resp rate less than 12; may indicate neurologic or electrolyte
disturbances, infection, or conscious response to protect against the
pain of pleurisy or other irritative pneumonia. Can also be 2/2 level of
cardio fitness
Hyperventilation
ANSWER:
term for fast and deep, heavy respirations, can be caused by exercise,
anxiety, and CNS and metabolic diseases
Hyperpnea
ANSWER:
term for abnormally deep respirations
,Kussmaul respirations
ANSWER:
deep and mostly rapid respirations, used to describe resp effort of
metabolic acidosis
Cheyne stokes respirations
ANSWER:
regular breathing with intervals of apnea by crescendo decrescendo
breathing; can be seen in sleeping pts, but mostly pts who are very ill,
esp with brain damage
Biot respirations
ANSWER:
irregular breathing that varies in depth and is interrupted irregularly
by intervals of apnea; associated with severe and persistent
increased intracranial pressure, resp compromise from drug
poisoning, or brain damage at the medulla and generally equals poor
prognosis
Peripheral areas related to respiratory assessment
ANSWER:
observe the lips and nails for cyanosis or pallor; lips for pursing;
fingers for clubbing; and alae nasi for flaring
Pleural friction rub
ANSWER:
dry, rubbing, or grating sound; palpable, coarse, grating vibration;
usually on inspiration; caused by inflammation of the pleural surfaces;
think feel of leather rubbing on leather
Thoracic expansion
ANSWER:
, stand behind patient and place thumbs along spinal process at level
of 10th rib, with palms lightly in contact with the posterolateral
surfaces; watch the thumbs during quiet and deep breathing; loss of
symmetry = problem on either 1 or both sides.
Crepitus
ANSWER:
crackly/crinkly sensation that can be palpated and heard, a gentle
bubbly feeling; indicates air in the subcutaneous tissue from a rupture
somewhere in the resp system, or infection with gas producing
organism
Palpating the chest and trachea
ANSWER:
palpate the throracic muscles and skeleton; feeling for pulsations,
areas of tenderness, bulges, depressions, masses, and unusual
movement
Tactile fremitus
ANSWER:
palpable vibration of the chest wall that results from speech or other
verbalizations. best felt posteriorly and laterally at the level of the
bifurcation of the bronchi; have patient say "99" while you palpate
with palmer surface of fingers or ulner aspect of the hand; use firm,
light touch
Abnormal tactile fremitus
ANSWER:
decreased of absent fremitus may be caused by excess air in lungs or
may indicate emphysema, pleural thickening, or effusion, massive
pulm edema, or bronchial obstruction. Increased fremitus often
coarser or rougher in feel, caused by presence of fluids or solid mass
within the lungs.
