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1. What action should be recommended if the APGAR score is 3 - Correct
Answer: Resuscitate
2. What action should be recommended if the APGAR score is 8? - Correct
Answer: Monitor routine care
3. Orthopnea - Correct Answer: Difficult breathing except in the upright
position (CHF)
4. General malise - Correct Answer: Run down feeling, nausea, weakness.
fatigue. headache (check electrolyte imbalance)
5. Dyspnea - Correct Answer: A feeling of shortness of breath or difficulty
breathing
6. Dysphagia - Correct Answer: Difficulty swallowing and hoarseness are
common symptoms
,7. Peripheral Edema - Correct Answer: Fluid in the arms and legs
Recommend a Diuretic
Pathology: Presence of excessive fluid in the tissue as pitting edema caused
by CHF and renal failure
8. Ascites - Correct Answer: Accumulation of fluid in the abdomen
generally caused by liver failure.
Pathology: Abdominal infection
9. Clubbing of fingers - Correct Answer: Caused by chronic hypoxemia
Pathology: Pulmonary disease COPD, CHF
The thumb and first fingers are affected.
10.Venous Distention - Correct Answer: Increased venous distention,
jugular distention (JVD) temporal veins popping out
Pathology: occurs with CHF, seen during exhalation in patients with COPD.
11.Capillary refill - Correct Answer: Indication of peripheral circulation
Pathology: blanching the hand and watch for color return
Color should return within 3 seconds
12.Diaphoresis - Correct Answer: A state of profuse/heavy sweating, heart
failure recommend diuretics. positive inotropic agents.
Pathology: fever infection (recommend antibiotics), anxiety nervousness
(recommend sedatives), tuberculosis/night sweats (recommend antitubular
gram stain)
,13.Ashen/pallor - Correct Answer: Abnormal
Indicates: anemia, blood loss, (vasoconstriction will cause color change by
reducing blood)
14.Erythema - Correct Answer: Redness of the skin
Indicates: due to capillary congestion, inflammation or infection
15.Cyanosis - Correct Answer: Blue or blue-gray dusky discoloration of the
skin and mucous membranes.
Indicates: hypoxia from increased amount of reduced hemoglobin
16.Chest configuration Kyphosiscoliosis - Correct Answer: Convex curvature
of the spine with a lateral curvature of the skin
- causes a restrictive pattern and reduced lung volumes.
17.Describe symmetrical chest movement - Correct Answer: When both
sides of the chest are moving equally at the same time
18.List five underlying pathologies that can contribute to a patient displaying
asymmetrical chest movement - Correct Answer: Post lung resection,
post pneumonectomy
Atelectasis (hyperinflation recruitment maneuver
Flail chest
Pneumothorax
Endotracheal tube inserted in right or left mainstem bronchi
, 19.Eupnea - Correct Answer: Normal respiratory rate, depth and rhythm
Condition: normal respiratory rate for an adult 12-20bpm
20.Tachypnea - Correct Answer: Increased respiratory rate >20bpm
Condition: hypoxia, fever, pain, CNS problem
21.Bradypnea - Correct Answer: Decreased respiratory rate <12bpm
Condition: sleep, drugs, alcohol, metabolic disorder
22.Cheyne-Stokes - Correct Answer: Gradually increasing then decreasing
rate and depth in a cycle lasting from 30-180 secs with periods of apnea up
to 60 secs.
Condition: increased intracranial pressures, brainstem injury, drug overdose
23.Biot's - Correct Answer: Increased respiratory rate and depth with
irregular periods of apnea
Condition: CNS depression
24.Kussmaul's - Correct Answer: Increased respiratory rate (usually 20
breaths/min)
Condition: increased depth rhythm, breathing sounds labored metabolic
acidosis, renal failure, diabetic ketoacidosis
25.What causes hypertrophy of the accessory muscles and what type of
patient might this be present in? - Correct Answer: Increase in muscle
size of accessory muscle occurs with COPD