ETSU NRSE 2350 PCC1 QUESTIONS WITH COMPLETE
SOLUTIONS
Common errors in BP readings? Correct Answer -Cuff too
narrow/short= false high BP
-Deflating cuff too quickly=false low systolic/high diastolic
-Deflating cuff too slowly=false high diastolic
-Failure to wait 1-2 minutes between readings= false high
diastolic
Describe adventitious lung sounds. Correct Answer *Crackles
(fine)* -discontinuous, high pitched, short popping heard on
inspiration
Sudden airway opening
Restrictive disease - pneumonia or heart failure
Obstructive disease - COPD
*Crackles (course)* - loud, low-pitched bubbling on early
inspiration
Air collides with secretions
Pulmonary edema - pneumonia, fibrosis, terminally ill
*Wheezing* - high-pitched musical squeaking on expiration
Narrowed passage ways
Diffuse air way obstruction
CODP
*Stridor* - high-pitched monophonic crowing on inspiration
(possible life threatening)
Upper airway obstruction
Croup or acute epiglottitis
Foreign body inhalation
,Describe heart murmurs. Correct Answer A blowing,
swishing sound due to turbulent blood flow.
Classified as Innocent or Functional (usually normal) or
Pathological (abnormal)
*Location* - Aortic, pulmonic, Tricuspid, Mitral (Always
Pumps To Much)
*Type* - Stenosis & Regurgitation (too hard vs. too soft)
Describe how to perform heart sound auscultation. Correct
Answer Begin @ 2nd ICS RSB-Aortic,
then 2nd ICS LSB-Pulmonic,
then 5th ICS LSB-Tricuspid,
then 5th ICS LMC-Mitral
Describe inspection & palpation of the thorax. Correct Answer
Facial expression & LOC- relaxed, AOOX3
Tense, pursed lip breathing; restlessness or irritability (air
hunger); drowsiness or confusion (hypoxia)
Shape and configuration - symmetrical, elliptical, downward
sloping ribs, costal angle (90 degrees)
Skeletal deformities (scoliosis, kyphosis, barrel chest) may limit
chest expansion = decreased ventilation
Positioning - relaxed able to support own weight with out
leaning on arms
Tripod positioning
Skin color and condition - consistent with genetic background
and sun exposure
Note abnormal color changes of the skin, lips, and nails
(cyanosis, pallor) and lesions or deformities (clubbing)
Respiratory RATE (10-12) - 20
QUALITY - deep or shallow
, NAILBEDS - color, thickness, capillary refill
TRACHEA- midline
USE OF ACCESSORY MUSCLES
Intercostal Retractions
SKIN COLOR - cyanosis
PURPOSE: TENDERNESS, LESIONS, TEMP. & MOISTURE
SYMMETRIC EXPANSION-diaphragmatic excursion
TACTILE FREMITIS: SOUND TRANSMISSION
Describe the cardiac cycle? Correct Answer *Diastole*
Ventricles relaxed
AV valves (tricuspid and mitral) are open (silent)
Blood pores from the atria into the ventricles
(protodiastolic/passive filling) (S3)
Atrial contraction (atrial kick) -active filling/pre-systole (S4)
*Systole*
AV valves (tricuspid and mitral) close (S1) Beginning
Isometric contraction - ventricle walls contract
Pressure in the ventricle exceeds aortic pressure
Blood ejection into aorta and pulmonary artery
Closure of the semilunar valves (aortic & pulmonic)
(S2) End
Isometric relaxation - all four valves are closed and ventricles
relaxed building atrial pressure
Describe the heart sounds heard during auscultation Correct
Answer *Normal Heart Sounds*
S1 - closure of mitral and tricuspid valves Loudest at the apex
(mitral valve)
S2- closure of the aortic and pulmonic valves Loudest at the
base (aortic valve)
SOLUTIONS
Common errors in BP readings? Correct Answer -Cuff too
narrow/short= false high BP
-Deflating cuff too quickly=false low systolic/high diastolic
-Deflating cuff too slowly=false high diastolic
-Failure to wait 1-2 minutes between readings= false high
diastolic
Describe adventitious lung sounds. Correct Answer *Crackles
(fine)* -discontinuous, high pitched, short popping heard on
inspiration
Sudden airway opening
Restrictive disease - pneumonia or heart failure
Obstructive disease - COPD
*Crackles (course)* - loud, low-pitched bubbling on early
inspiration
Air collides with secretions
Pulmonary edema - pneumonia, fibrosis, terminally ill
*Wheezing* - high-pitched musical squeaking on expiration
Narrowed passage ways
Diffuse air way obstruction
CODP
*Stridor* - high-pitched monophonic crowing on inspiration
(possible life threatening)
Upper airway obstruction
Croup or acute epiglottitis
Foreign body inhalation
,Describe heart murmurs. Correct Answer A blowing,
swishing sound due to turbulent blood flow.
Classified as Innocent or Functional (usually normal) or
Pathological (abnormal)
*Location* - Aortic, pulmonic, Tricuspid, Mitral (Always
Pumps To Much)
*Type* - Stenosis & Regurgitation (too hard vs. too soft)
Describe how to perform heart sound auscultation. Correct
Answer Begin @ 2nd ICS RSB-Aortic,
then 2nd ICS LSB-Pulmonic,
then 5th ICS LSB-Tricuspid,
then 5th ICS LMC-Mitral
Describe inspection & palpation of the thorax. Correct Answer
Facial expression & LOC- relaxed, AOOX3
Tense, pursed lip breathing; restlessness or irritability (air
hunger); drowsiness or confusion (hypoxia)
Shape and configuration - symmetrical, elliptical, downward
sloping ribs, costal angle (90 degrees)
Skeletal deformities (scoliosis, kyphosis, barrel chest) may limit
chest expansion = decreased ventilation
Positioning - relaxed able to support own weight with out
leaning on arms
Tripod positioning
Skin color and condition - consistent with genetic background
and sun exposure
Note abnormal color changes of the skin, lips, and nails
(cyanosis, pallor) and lesions or deformities (clubbing)
Respiratory RATE (10-12) - 20
QUALITY - deep or shallow
, NAILBEDS - color, thickness, capillary refill
TRACHEA- midline
USE OF ACCESSORY MUSCLES
Intercostal Retractions
SKIN COLOR - cyanosis
PURPOSE: TENDERNESS, LESIONS, TEMP. & MOISTURE
SYMMETRIC EXPANSION-diaphragmatic excursion
TACTILE FREMITIS: SOUND TRANSMISSION
Describe the cardiac cycle? Correct Answer *Diastole*
Ventricles relaxed
AV valves (tricuspid and mitral) are open (silent)
Blood pores from the atria into the ventricles
(protodiastolic/passive filling) (S3)
Atrial contraction (atrial kick) -active filling/pre-systole (S4)
*Systole*
AV valves (tricuspid and mitral) close (S1) Beginning
Isometric contraction - ventricle walls contract
Pressure in the ventricle exceeds aortic pressure
Blood ejection into aorta and pulmonary artery
Closure of the semilunar valves (aortic & pulmonic)
(S2) End
Isometric relaxation - all four valves are closed and ventricles
relaxed building atrial pressure
Describe the heart sounds heard during auscultation Correct
Answer *Normal Heart Sounds*
S1 - closure of mitral and tricuspid valves Loudest at the apex
(mitral valve)
S2- closure of the aortic and pulmonic valves Loudest at the
base (aortic valve)
