NUR216 EXAM 2 STUDY GUIDE WITH COMPLETE
SOLUTION!!
1. Wheezes: continuous, high-pitched squeak or musical sound made as
air moves through narrowed or partially obstructed airway passages
2. Crackles: fine crackling or bubbling sounds, commonly heard during
inspiration when there is fluid in the alveoli; also called rales
3. Stridor: strained, high-pitched sound heard on inspiration caused by
obstruction in the pharynx or larynx
4. Rhonchi: Coarse, low-pitched breath sounds are heard in patients
with chronic mucus in the upper airways.
5. ABCDE: asymmetry, border, color, diameter, evolving
6. How can we prevent pressure ulcers?: turning patients every 2 hours
who are bedridden. Appropriate nutrition and hydration. float heels off
bed, clean linens, doing incontinence care, movement of patients,
barrier cream and wound care of places susceptible to ulcers.
7. You are assessing a client who has irregular border? What questions
would ask?: Have you noticed in changes in color?
How long has it been
there? Family History?
Tanning
beds?
Occupation?
Sunscreen?
8. Undetermined/Diagnosed lesions or rashes: Comfort? Does it limit your
activ- ities?
Is there any pain?
Any alleviating/relieving factors?
Any rash or lesions anywhere in your
body? Exposure?
When did you first notice it?
9. Risk Factors for Pressure Ulcers: Limited
mobility moisture
friction
paralysis
immobili
ty
decreased level of consciousness
10.Pressure Ulcer Stage 1: Intact skin with non-blanchable redness of a
1/
, localized area, usually over a bony prominence; skin is not broken but is
red or discolored; partial thickness skin loss; skin can be warm or cool
2/
SOLUTION!!
1. Wheezes: continuous, high-pitched squeak or musical sound made as
air moves through narrowed or partially obstructed airway passages
2. Crackles: fine crackling or bubbling sounds, commonly heard during
inspiration when there is fluid in the alveoli; also called rales
3. Stridor: strained, high-pitched sound heard on inspiration caused by
obstruction in the pharynx or larynx
4. Rhonchi: Coarse, low-pitched breath sounds are heard in patients
with chronic mucus in the upper airways.
5. ABCDE: asymmetry, border, color, diameter, evolving
6. How can we prevent pressure ulcers?: turning patients every 2 hours
who are bedridden. Appropriate nutrition and hydration. float heels off
bed, clean linens, doing incontinence care, movement of patients,
barrier cream and wound care of places susceptible to ulcers.
7. You are assessing a client who has irregular border? What questions
would ask?: Have you noticed in changes in color?
How long has it been
there? Family History?
Tanning
beds?
Occupation?
Sunscreen?
8. Undetermined/Diagnosed lesions or rashes: Comfort? Does it limit your
activ- ities?
Is there any pain?
Any alleviating/relieving factors?
Any rash or lesions anywhere in your
body? Exposure?
When did you first notice it?
9. Risk Factors for Pressure Ulcers: Limited
mobility moisture
friction
paralysis
immobili
ty
decreased level of consciousness
10.Pressure Ulcer Stage 1: Intact skin with non-blanchable redness of a
1/
, localized area, usually over a bony prominence; skin is not broken but is
red or discolored; partial thickness skin loss; skin can be warm or cool
2/
