NCCC Nur 211 Test 1 (summer) Questions and Answers 100% Pass

NCCC Nur 211 Test 1 (summer)
Questions and Answers 100% Pass


Chest Assessment Abreviations - ✔✔IPPA - Inspection, Palpation,

Percussion, Auscultation


Inspections - ✔✔Look for deformities, retraction, symmetry, rate, rhythm

of breathing, pursed lip breathing, use of accessory muscles


Palpation - ✔✔an examination technique in which the examiner's hands are

used to feel the texture, size, consistency, and location of certain body parts


Observe for tenderness, abnormalities, elicit vocal and tactile fremitus


Percussion - ✔✔tapping on a surface to determine the difference in the

density of the underlying structure


Observe for dullness, flatness, resonance, hyper resonance, tympany


Auscultation - ✔✔Listening with a stethoscope


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,Listen to both sides and compare tracheal, bronchial, bronchovesicular,

vesicular


Tracheal Breath Sounds - ✔✔very loud, harsh sounds that are heard by

listening over the trachea in the neck


Bronchial breath sounds - ✔✔normal breath sounds made by air moving

through the bronchi, harsh, tubular quality


Bronchovesicular breath sounds - ✔✔inspiration is unchanged from that of

vesicular breathing, but expiration is as loud, equal in length and similar in

pitch


fine crackles breath sounds - ✔✔rales, sounds similar to rubbing hair

together, can be found in CHF, emphysema, or pneumonia; probably

produced by reopening of small airways or alveoli that are collapsed

during previous expiration or fluid in the alveoli


course breath sounds - ✔✔gurgles or rhonchi, continuous sound produced

when air passes through narrowed bronchus; found in COPD and CHF;

gurgles heard on both inspiration and expiration; can change with cough



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,wheeze breath sounds - ✔✔whistling or sighing that results from

narrowing of the lumen of the respiratory passageway; Usually on

expiration;


Asthma, COPD, foreign body aspiration


pleural friction rub - ✔✔continuous, dry grating sound caused by

inflammation of pleural surfaces and loss of lubricating pleural fluid;

produced when two inflamed surfaces rub together during respiration

cycle; found in pleurisy, TB, pulmonary infarction, pneumonia, or lung

cancer


Front View Ausculatation - ✔✔RUL, LUL, LLL, RLL, RML


Back view ausculatation - ✔✔LUL, RUL, LLL, RLL


How many points to check anteriorly during auscultation? - ✔✔10 at

minimum


fremitus - ✔✔a palpable vibration from the spoken voice felt over the chest

wall


Normal percussion sound in lung - ✔✔Resonance


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, Egophany - ✔✔"ee" to "ay" change


suggests lobar consolidation. (most common in patients with pneumonia)


The sound of the ee heard through the stethescope; muffled is normal; clear

ay is abnormal


Bronchophony - ✔✔the spoken voice sound heard through the stethoscope,

which sounds soft, muffled, and indistinct over normal lung tissue; "99"


whispered pectoriloquy - ✔✔a whispered phrase heard through the

stethoscope that sounds faint and inaudible over normal lung tissue


reasons to suction trach - ✔✔wheezes crackles gurgling on inspiration or

expiration audible without auscultation, unexplained increase in work of

breathing; vomiting, cyanosis, increased pulse and respirations


Nursing diagnosis for trach care - ✔✔ineffective airway clearance;

ineffective breathing pattern; altered O2/CO2


Yankauer Suction - ✔✔a large filter-tipped rigid plastic suction catheter

used mainly in the mouth or other large body cavity; least invasive trach

suction available; clean technique with gloves and goggles


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