NR302 Final Comprehensive Exam GUARANTEED
PASS!!
Actual Dx - (ANSWER)Actual Diagnosis related to (R/T) ________(Related Factors) as
evidenced by (AEB) ________ (Defining Characteristics)
Risk - (ANSWER)Risk for __________as evidenced by _________ (Risk Factors).
Readiness - (ANSWER)Readiness for __________as evidenced by "_________" (Defining
characteristics).
Asthma - (ANSWER)chronic hyper-reactive condition. Obstruction. Wheezing. Dyspnea,
increased RR, use of accessory muscles, anxiety, prolonged expiration.
Palpation- decreased tactile fremitus
Percussion- resonance. Hyperresonance with chronic.
Auscultation- wheezing, decreased voice sounds. Severe; no breath sounds.
Atelectasis - (ANSWER)obstruction of airflow. Increased RR, dyspnea, cyanosis, trachea shift to
affected side in severe cases.
Palpation- lack of tactile fremitus. decreased lung expansion on affected side
Percussion- dullness over affected area
Auscultate- absent or diminished but normal breath sounds bilaterally.
Chronic Bronchitis - (ANSWER)inflammation of tracheobronchial tree. Early morning,
congested, chronic productive cough. White or clear sputum. Wheezes or rhonchi. Dyspnea,
tachypnea, use of accessory muscles.
Emphysema - (ANSWER)COPD. Obstruction of the alveoli. Tripod posture. Use of accessory
muscles. Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on exertion.
Palpation- Absent or decreased tactile fremitus. Decreased chest expansion.
Page 1 of 21
,Percussion- Hyper-resonance.
Auscultate- diminished but normal breath sounds bilaterally, decreased vesicular sounds,
wheezing.
COPD - (ANSWER)>90 costal angle. Barrel chest AP=T. ↓ Tactile fremitus palp. Tripod
posture. Use of accessory muscles. Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on
exertion.
Lobular Pneumonia - (ANSWER)infection of the alveoli, Consolidation. Tachypnea, congested,
hacking, productive cough, chills, chest pain with breathing. Mucosal edema. Sputum- rust.
Palpation- increased tactile fremitus. Decreased chest expansion on affected side.
Percussion- dullness over affected area.
Auscultation- Egophony changes e to a. Clear Whispered pectoriloguy & bronchophony.
Bronchial breath sounds and crackles.
Pleural effusion - (ANSWER)fluid in the pleural space. Dyspnea. Tracheal shift to unaffected
side.
Palpation- Absent or decreased tactile fremitus. decreased chest expansion side affected.
Percussion- Dullness
Auscultation- unilateral lung sounds. Decreased/absent breath/voice sounds. Pleural rub.
Pneumothorax - (ANSWER)air in pleural space, collapse of the lung. Tachypnea, tracheal shift
to unaffected side.
Palpation- Decreased Tactile fremitus. Unilateral decrease or delay in respiratory expansion.
Percussion- Hyper-resonance
Auscultation- unilateral of normal lung sounds. Decreased/absent breath/voice sounds.
Congestive heart failure - (ANSWER)Increased pressure in the pulmonary veins causes
interstitial edema around the alveoli and may cause edema of the bronchial mucosa. Pulmonary
congestion.
Increased respiratory rate, shortness of breath (especially on exertion), orthopnea, peripheral
edema, pallor. S3. Hypertrophy. Dry cough.
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, Palpation- Normal tactile fremitus. Skin cool and clammy.
Percussion- Resonance.
Auscultation-Normal breath sounds and voice sounds. Wheezes or crackles at the bases of the
lungs.
◦ Left-sided CHF - (ANSWER)lung symptoms. 1st Fatigue. Pink frothy sputum. Pulmonary
edema. Hypoxia. SOB, crackles/rales, cough, orthopnea, anxiety, confusion, PND. S3
Rt CHF - (ANSWER)peripheral symptoms. Skin pale, gray, or cyanotic; nausea, vomiting;
pitting edema, peripheral/bilateral edema, ascites, JVD, HJR, weak pulse, cool moist skin,
decreased urine output, increased B.P., weight gain, liver congestion. Cor Pulmonale
Crackles/Rales - (ANSWER)discontinuous, intermittent, non-musical, and brief. C-collapsed or
fluid-filled alveoli open. end inspiration, do not clear w cough.
Fine rales - (ANSWER)soft, high pitched, and very brief.
Coarse rales/crackles - (ANSWER)louder, moist, lower in pitch, longer, bubbling.
Wheezes (sibilant) - (ANSWER)inspiration/expiration when severe. continuous high pitched
with a shrill quality. C- blocked air flow; asthma, infection, foreign body obstruction.
Rhonchi (sonorous) - (ANSWER)Expiration/ inspiration. Change/disappear w cough.
Continuous low pitched with a snoring, rattling. Fluid-blocked airways.
Stridor - (ANSWER)inspiration. Loud high pitched crowing heard without stethoscope.
Obstructed upper airways.
Friction rub - (ANSWER)inhalation/exhalation. Low pitched grating, rubbing, pleural
inflammation
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PASS!!
Actual Dx - (ANSWER)Actual Diagnosis related to (R/T) ________(Related Factors) as
evidenced by (AEB) ________ (Defining Characteristics)
Risk - (ANSWER)Risk for __________as evidenced by _________ (Risk Factors).
Readiness - (ANSWER)Readiness for __________as evidenced by "_________" (Defining
characteristics).
Asthma - (ANSWER)chronic hyper-reactive condition. Obstruction. Wheezing. Dyspnea,
increased RR, use of accessory muscles, anxiety, prolonged expiration.
Palpation- decreased tactile fremitus
Percussion- resonance. Hyperresonance with chronic.
Auscultation- wheezing, decreased voice sounds. Severe; no breath sounds.
Atelectasis - (ANSWER)obstruction of airflow. Increased RR, dyspnea, cyanosis, trachea shift to
affected side in severe cases.
Palpation- lack of tactile fremitus. decreased lung expansion on affected side
Percussion- dullness over affected area
Auscultate- absent or diminished but normal breath sounds bilaterally.
Chronic Bronchitis - (ANSWER)inflammation of tracheobronchial tree. Early morning,
congested, chronic productive cough. White or clear sputum. Wheezes or rhonchi. Dyspnea,
tachypnea, use of accessory muscles.
Emphysema - (ANSWER)COPD. Obstruction of the alveoli. Tripod posture. Use of accessory
muscles. Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on exertion.
Palpation- Absent or decreased tactile fremitus. Decreased chest expansion.
Page 1 of 21
,Percussion- Hyper-resonance.
Auscultate- diminished but normal breath sounds bilaterally, decreased vesicular sounds,
wheezing.
COPD - (ANSWER)>90 costal angle. Barrel chest AP=T. ↓ Tactile fremitus palp. Tripod
posture. Use of accessory muscles. Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB on
exertion.
Lobular Pneumonia - (ANSWER)infection of the alveoli, Consolidation. Tachypnea, congested,
hacking, productive cough, chills, chest pain with breathing. Mucosal edema. Sputum- rust.
Palpation- increased tactile fremitus. Decreased chest expansion on affected side.
Percussion- dullness over affected area.
Auscultation- Egophony changes e to a. Clear Whispered pectoriloguy & bronchophony.
Bronchial breath sounds and crackles.
Pleural effusion - (ANSWER)fluid in the pleural space. Dyspnea. Tracheal shift to unaffected
side.
Palpation- Absent or decreased tactile fremitus. decreased chest expansion side affected.
Percussion- Dullness
Auscultation- unilateral lung sounds. Decreased/absent breath/voice sounds. Pleural rub.
Pneumothorax - (ANSWER)air in pleural space, collapse of the lung. Tachypnea, tracheal shift
to unaffected side.
Palpation- Decreased Tactile fremitus. Unilateral decrease or delay in respiratory expansion.
Percussion- Hyper-resonance
Auscultation- unilateral of normal lung sounds. Decreased/absent breath/voice sounds.
Congestive heart failure - (ANSWER)Increased pressure in the pulmonary veins causes
interstitial edema around the alveoli and may cause edema of the bronchial mucosa. Pulmonary
congestion.
Increased respiratory rate, shortness of breath (especially on exertion), orthopnea, peripheral
edema, pallor. S3. Hypertrophy. Dry cough.
Page 2 of 21
, Palpation- Normal tactile fremitus. Skin cool and clammy.
Percussion- Resonance.
Auscultation-Normal breath sounds and voice sounds. Wheezes or crackles at the bases of the
lungs.
◦ Left-sided CHF - (ANSWER)lung symptoms. 1st Fatigue. Pink frothy sputum. Pulmonary
edema. Hypoxia. SOB, crackles/rales, cough, orthopnea, anxiety, confusion, PND. S3
Rt CHF - (ANSWER)peripheral symptoms. Skin pale, gray, or cyanotic; nausea, vomiting;
pitting edema, peripheral/bilateral edema, ascites, JVD, HJR, weak pulse, cool moist skin,
decreased urine output, increased B.P., weight gain, liver congestion. Cor Pulmonale
Crackles/Rales - (ANSWER)discontinuous, intermittent, non-musical, and brief. C-collapsed or
fluid-filled alveoli open. end inspiration, do not clear w cough.
Fine rales - (ANSWER)soft, high pitched, and very brief.
Coarse rales/crackles - (ANSWER)louder, moist, lower in pitch, longer, bubbling.
Wheezes (sibilant) - (ANSWER)inspiration/expiration when severe. continuous high pitched
with a shrill quality. C- blocked air flow; asthma, infection, foreign body obstruction.
Rhonchi (sonorous) - (ANSWER)Expiration/ inspiration. Change/disappear w cough.
Continuous low pitched with a snoring, rattling. Fluid-blocked airways.
Stridor - (ANSWER)inspiration. Loud high pitched crowing heard without stethoscope.
Obstructed upper airways.
Friction rub - (ANSWER)inhalation/exhalation. Low pitched grating, rubbing, pleural
inflammation
Page 3 of 21
