Comprehensive Nursing495 concepts exam with
questions and answers (100% solved)
, Comprehensive Nursing495 concepts exam with questions and
answers (100% solved)
CARDIAC and PULM
● Introduced + hand hygiene
● Pt name and DOB
● Where are we? What is the Year?
○ Patient is awake, alert, and oriented to time, place and self, she is well-groomed,
makes eye contact, and speech is clear and appropriate.
● Be on pt’s rt side
● I will be doing a heart and lung assessment on you today. Do you have any questions for
me?
● Ask them about their norms for Vital Signs (since we are virtual)
● Turn head to the left - look for the pulsation and JV
○ No distention in the jugular vein
● Look straight - look for carotid pulse
○ Lower half the neck
○ Palate the other side - never palate them at the same time
○ No trilled were noted during palpation
● Use stethoscope to listen for bruits - listen with both bell and diaphragm - Listen to both
sides
○ No bruits were noted during auscultation
● Inspect the chest - look for pulsations, abnormal rises and fall, symmetry
○ There is a rise and fall on the chest, no asymmetry was noted
○ Skin is warm, color is appropriate
● Palpate - start in the middle and then go to the left from second intercostal
to 3→ 4→ 5th (apical pulse)
○ Palpating for thrills and the point of maximal impulse and crepitus (front and back)
○ No thrills were noted
○ No crepitus were noted
○ Palpate for lung expansion (front and back)
○ Symmetrical expansion noted
● Auscultate heart sounds - start with the diaphragm and then listen with bell
○ 2nd intercostal space on the right - aortic
○ 2nd intercostal space on the left - pulmonic
○ Erb’s point - 3rd
○ Tricuspid - 4th
○ Mitral - 5th
○ No s3 or s4 were noted
● Auscultate lungs - 6 in front, 8 in back-mention we are assessing them directly on the skin
○ Lungs are clear to auscultation bilaterally, anterior and posterior
questions and answers (100% solved)
, Comprehensive Nursing495 concepts exam with questions and
answers (100% solved)
CARDIAC and PULM
● Introduced + hand hygiene
● Pt name and DOB
● Where are we? What is the Year?
○ Patient is awake, alert, and oriented to time, place and self, she is well-groomed,
makes eye contact, and speech is clear and appropriate.
● Be on pt’s rt side
● I will be doing a heart and lung assessment on you today. Do you have any questions for
me?
● Ask them about their norms for Vital Signs (since we are virtual)
● Turn head to the left - look for the pulsation and JV
○ No distention in the jugular vein
● Look straight - look for carotid pulse
○ Lower half the neck
○ Palate the other side - never palate them at the same time
○ No trilled were noted during palpation
● Use stethoscope to listen for bruits - listen with both bell and diaphragm - Listen to both
sides
○ No bruits were noted during auscultation
● Inspect the chest - look for pulsations, abnormal rises and fall, symmetry
○ There is a rise and fall on the chest, no asymmetry was noted
○ Skin is warm, color is appropriate
● Palpate - start in the middle and then go to the left from second intercostal
to 3→ 4→ 5th (apical pulse)
○ Palpating for thrills and the point of maximal impulse and crepitus (front and back)
○ No thrills were noted
○ No crepitus were noted
○ Palpate for lung expansion (front and back)
○ Symmetrical expansion noted
● Auscultate heart sounds - start with the diaphragm and then listen with bell
○ 2nd intercostal space on the right - aortic
○ 2nd intercostal space on the left - pulmonic
○ Erb’s point - 3rd
○ Tricuspid - 4th
○ Mitral - 5th
○ No s3 or s4 were noted
● Auscultate lungs - 6 in front, 8 in back-mention we are assessing them directly on the skin
○ Lungs are clear to auscultation bilaterally, anterior and posterior
