NR 203 Midterm Exam with Accurate Answers.
Latest Edition
ADPIE - ✔✔assessment, nursing diagnosis, planning - outcomes & interventions,
implementation, evaulation
First heart sound - ✔✔S1 - lub
AV valves close
Second heart sound - ✔✔S2 - dub
SL valves close
Third heart sound - ✔✔S3 right after S2
Fourth heart sound - ✔✔S4 right before S1
Murmurs - ✔✔sounds created by abnormal, turbulent flow of blood in the heart
gentle blowing, clicking, rushing or gurgling
Characteristics of murmurs - ✔✔timing (systole or diastole), loudness, intensity, pitch, pattern,
quality, duration
Cardiac output - ✔✔heart rate x stroke volume
how much blood is coming out of the heart every minute (~5L/min)
carotid arteries - ✔✔the major arteries that carry blood upward to the head
, Jugular veins - ✔✔empty unoxygenated blood from the head directly into the superior vena
cava
Dyspnea - ✔✔Shortness of breath
Orthopnea - ✔✔shortness of breath while laying flat
Stethoscope bell - ✔✔low pitched sounds (extra heart sounds, murmurs)
Stethoscope diaphragm - ✔✔high pitched sounds (breath, bowel, normal heart sounds)
Assess Carotid arteries - ✔✔semi-fowler, palpate on at a time, Auscultate for bruit with bell - if
has risk factors for CV do first and don't palpate if bruit present
Assess Jugular veins - ✔✔inspect venous pulse - head to side, lay down
if venous distension present need to measure
do not palpate
Assess precordium - ✔✔inspect anterior chest
palpate apical pulse - may need to roll pt to side
palpate across precordium - z pattern - lift, heave, vibration
percussion cardiac boarders in intercostal spaces
Aortic area landmark (AO) Apex - ✔✔2nd intercostal space, just to the right of the sternum
Pulmonic area landmark (PV) - ✔✔2nd intercostal space to the left of the sternum
Latest Edition
ADPIE - ✔✔assessment, nursing diagnosis, planning - outcomes & interventions,
implementation, evaulation
First heart sound - ✔✔S1 - lub
AV valves close
Second heart sound - ✔✔S2 - dub
SL valves close
Third heart sound - ✔✔S3 right after S2
Fourth heart sound - ✔✔S4 right before S1
Murmurs - ✔✔sounds created by abnormal, turbulent flow of blood in the heart
gentle blowing, clicking, rushing or gurgling
Characteristics of murmurs - ✔✔timing (systole or diastole), loudness, intensity, pitch, pattern,
quality, duration
Cardiac output - ✔✔heart rate x stroke volume
how much blood is coming out of the heart every minute (~5L/min)
carotid arteries - ✔✔the major arteries that carry blood upward to the head
, Jugular veins - ✔✔empty unoxygenated blood from the head directly into the superior vena
cava
Dyspnea - ✔✔Shortness of breath
Orthopnea - ✔✔shortness of breath while laying flat
Stethoscope bell - ✔✔low pitched sounds (extra heart sounds, murmurs)
Stethoscope diaphragm - ✔✔high pitched sounds (breath, bowel, normal heart sounds)
Assess Carotid arteries - ✔✔semi-fowler, palpate on at a time, Auscultate for bruit with bell - if
has risk factors for CV do first and don't palpate if bruit present
Assess Jugular veins - ✔✔inspect venous pulse - head to side, lay down
if venous distension present need to measure
do not palpate
Assess precordium - ✔✔inspect anterior chest
palpate apical pulse - may need to roll pt to side
palpate across precordium - z pattern - lift, heave, vibration
percussion cardiac boarders in intercostal spaces
Aortic area landmark (AO) Apex - ✔✔2nd intercostal space, just to the right of the sternum
Pulmonic area landmark (PV) - ✔✔2nd intercostal space to the left of the sternum
