NU 155 EXAM 1 SCRIPT COMPLETE ANSWERS GRADED A+
◉ bronchovesicular lung sounds
Answer: Medium pitch sound heard over main bronchus area and over upper right posterior lung
field. Equal inspiratory and expiratory.
◉ Bronchial lung sounds
Answer: heard over trachea; expiratory sound predominates; is higher pitched and louder
◉ crackles (rales)
Answer: short, discrete, interrupted, crackling sound classified as fine to coarse; caused by air passing
through secretions, moisture
◉ Gurgles (rhonchi)
,Answer: air passing through narrowed air passages as a result of secretions, swelling tumor.
continuous, low pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality. best
heard on expiration but can be heard on both inspiration and expiration
◉ friction rub
Answer: a coarse, grating, adventitious lung sound heard when the pleurae are inflamed
◉ wheeze
Answer: whistling or sighing sound heard on auscultation that results from narrowing of the lumen of
the respiratory passageway
◉ Romberg test
Answer: ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
expected finding: client should be able to stand with minimal swaying for at least 5 seconds
◉ UAP CAN
,Answer: Taking of vital signs
Measuring and recording intake and output
Client transfers and ambulation
Postmortem care
Bathing
Feeding
Gastrostomy feedings in established systems
Attending to safety
Weighing
Performing simple dressing changes
Suctioning of chronic tracheostomies
Performing basic life support (CPR)
◉ UAP CANNOT
Answer: Assessment
, Interpretation of data
Making a nursing diagnosis
Creation of a nursing care plan
Evaluation of care effectiveness
Care of invasive lines
Administering parenteral medications
Insertion of nasogastric tubes
Client education
Performing triage
Giving telephone advice
◉ Adult pulse range
Answer: 60-100
◉ Adult respiratory rate range
◉ bronchovesicular lung sounds
Answer: Medium pitch sound heard over main bronchus area and over upper right posterior lung
field. Equal inspiratory and expiratory.
◉ Bronchial lung sounds
Answer: heard over trachea; expiratory sound predominates; is higher pitched and louder
◉ crackles (rales)
Answer: short, discrete, interrupted, crackling sound classified as fine to coarse; caused by air passing
through secretions, moisture
◉ Gurgles (rhonchi)
,Answer: air passing through narrowed air passages as a result of secretions, swelling tumor.
continuous, low pitched, coarse, gurgling, harsh, louder sounds with a moaning or snoring quality. best
heard on expiration but can be heard on both inspiration and expiration
◉ friction rub
Answer: a coarse, grating, adventitious lung sound heard when the pleurae are inflamed
◉ wheeze
Answer: whistling or sighing sound heard on auscultation that results from narrowing of the lumen of
the respiratory passageway
◉ Romberg test
Answer: ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
expected finding: client should be able to stand with minimal swaying for at least 5 seconds
◉ UAP CAN
,Answer: Taking of vital signs
Measuring and recording intake and output
Client transfers and ambulation
Postmortem care
Bathing
Feeding
Gastrostomy feedings in established systems
Attending to safety
Weighing
Performing simple dressing changes
Suctioning of chronic tracheostomies
Performing basic life support (CPR)
◉ UAP CANNOT
Answer: Assessment
, Interpretation of data
Making a nursing diagnosis
Creation of a nursing care plan
Evaluation of care effectiveness
Care of invasive lines
Administering parenteral medications
Insertion of nasogastric tubes
Client education
Performing triage
Giving telephone advice
◉ Adult pulse range
Answer: 60-100
◉ Adult respiratory rate range
