Brookdale CC Unit 2 Exam NURS 171
Cheyne-Stokes breathing pattern - CORRECT ANSWER-pattern of breathing
characterized by a gradual increase of depth and sometimes rate to a maximum
level, followed by a decrease, resulting in apnea
Apnea breathing pattern - CORRECT ANSWER-absence of breathing
7 Respiratory efforts - CORRECT ANSWER-1. nasal flaring
2. retractions
3. grunting
4. body positioning to facilitate breathing
5.paroxysmal nocturnal dyspnea
6. conversational dyspnea
7. stridor
Stridor - CORRECT ANSWER-usually means a upper airway obstruction, high
pitched sound
Upper Respiratory Infection - CORRECT ANSWER-common cold, influenza
Lower Respiratory Infection - CORRECT ANSWER-pneumonia, acute bronchitis,
tuberculosis
Diagnostic test that best measures a client's level of hypoxemia - CORRECT
ANSWER-Arterial blood gas (ABGs) (mother of all oxygen tests)
Abnormal Gas Exchange is evidenced by - CORRECT ANSWER-abnormal pulse
oximetry, ABGs; dyspnea at rest, restlessness, cyanosis, somnolence (sleepy)
Factors that affect ventilation - CORRECT ANSWER-rate, depth, lung compliance,
lung elasticity, airway resistance
Abnormal airway patency indicators - CORRECT ANSWER-anxiety, fear, choking,
dyspnea, cyanosis, abnormal chest expansion, tactile fremitus, adventitious
breath sounds
Normal airway latency indicator - CORRECT ANSWER-open clear
tracheobronchial passages for air exchange
Ventilation - CORRECT ANSWER-movement of air in and out of the lungs
Edema - CORRECT ANSWER-puffy swelling of tissue from the accumulation of
fluid often assoc. with venous problems
, Arterial changes - CORRECT ANSWER-color is pale/brownish discoloration, cool
temp, decreased pulse, sensory loss, decreased skin growth with thin shiny skin
Pulse amplitude description and numbers = 0 - CORRECT ANSWER-may indicate
a decrease in cardiac output
Pulse amplitude description and numbers = 1+ - CORRECT ANSWER-diminished,
weak
Pulse amplitude description and numbers = 2+ - CORRECT ANSWER-normal
Pulse amplitude description and numbers = 3+ - CORRECT ANSWER-bounding;
may indicate hypertension/too much blood volume
what happens when the cardiac pump isn't working - CORRECT ANSWER-
distended neck veins, diaphoresis, dysrhythmias, peripheral edema, c/o nausea,
fatigue, pain, dyspnea, weight gain
Questions used to identify pertinent heart data - CORRECT ANSWER-chief
complaint, client's hx (chest pain, leg pain,swelling etc), family hx (HTN, HF,
myocardial infraction)
Cardiovascular assessment - CORRECT ANSWER-- measure orthostatic BP and
pulse, and assess
for vertigo;
- palpate apical and peripheral pulses;
- auscultate heart at apex for S3 --- which is an early sign of heart failure;
- palpate for edema in the sacrum, legs, and feet;
- palpate skin for warmth in peripheral areas to include
nose, ear lobes, hands, and feet;
- assess for DVT by observing calves for redness
and palpating for warmth and tenderness;
- measure circumference of both calves and thighs and
compare in size
Assessing fatigue r/t cardiac system - CORRECT ANSWER-fatigue is often a sign
of oxygenation problems: anemia or heart failure
Cardiac pain in men - CORRECT ANSWER-center or side chest pain that radiates
to the L arm
Cardiac pain in women - CORRECT ANSWER-reports of feeling sick, fatigue, body
pain, jaw pain, neck/arm pain
Cheyne-Stokes breathing pattern - CORRECT ANSWER-pattern of breathing
characterized by a gradual increase of depth and sometimes rate to a maximum
level, followed by a decrease, resulting in apnea
Apnea breathing pattern - CORRECT ANSWER-absence of breathing
7 Respiratory efforts - CORRECT ANSWER-1. nasal flaring
2. retractions
3. grunting
4. body positioning to facilitate breathing
5.paroxysmal nocturnal dyspnea
6. conversational dyspnea
7. stridor
Stridor - CORRECT ANSWER-usually means a upper airway obstruction, high
pitched sound
Upper Respiratory Infection - CORRECT ANSWER-common cold, influenza
Lower Respiratory Infection - CORRECT ANSWER-pneumonia, acute bronchitis,
tuberculosis
Diagnostic test that best measures a client's level of hypoxemia - CORRECT
ANSWER-Arterial blood gas (ABGs) (mother of all oxygen tests)
Abnormal Gas Exchange is evidenced by - CORRECT ANSWER-abnormal pulse
oximetry, ABGs; dyspnea at rest, restlessness, cyanosis, somnolence (sleepy)
Factors that affect ventilation - CORRECT ANSWER-rate, depth, lung compliance,
lung elasticity, airway resistance
Abnormal airway patency indicators - CORRECT ANSWER-anxiety, fear, choking,
dyspnea, cyanosis, abnormal chest expansion, tactile fremitus, adventitious
breath sounds
Normal airway latency indicator - CORRECT ANSWER-open clear
tracheobronchial passages for air exchange
Ventilation - CORRECT ANSWER-movement of air in and out of the lungs
Edema - CORRECT ANSWER-puffy swelling of tissue from the accumulation of
fluid often assoc. with venous problems
, Arterial changes - CORRECT ANSWER-color is pale/brownish discoloration, cool
temp, decreased pulse, sensory loss, decreased skin growth with thin shiny skin
Pulse amplitude description and numbers = 0 - CORRECT ANSWER-may indicate
a decrease in cardiac output
Pulse amplitude description and numbers = 1+ - CORRECT ANSWER-diminished,
weak
Pulse amplitude description and numbers = 2+ - CORRECT ANSWER-normal
Pulse amplitude description and numbers = 3+ - CORRECT ANSWER-bounding;
may indicate hypertension/too much blood volume
what happens when the cardiac pump isn't working - CORRECT ANSWER-
distended neck veins, diaphoresis, dysrhythmias, peripheral edema, c/o nausea,
fatigue, pain, dyspnea, weight gain
Questions used to identify pertinent heart data - CORRECT ANSWER-chief
complaint, client's hx (chest pain, leg pain,swelling etc), family hx (HTN, HF,
myocardial infraction)
Cardiovascular assessment - CORRECT ANSWER-- measure orthostatic BP and
pulse, and assess
for vertigo;
- palpate apical and peripheral pulses;
- auscultate heart at apex for S3 --- which is an early sign of heart failure;
- palpate for edema in the sacrum, legs, and feet;
- palpate skin for warmth in peripheral areas to include
nose, ear lobes, hands, and feet;
- assess for DVT by observing calves for redness
and palpating for warmth and tenderness;
- measure circumference of both calves and thighs and
compare in size
Assessing fatigue r/t cardiac system - CORRECT ANSWER-fatigue is often a sign
of oxygenation problems: anemia or heart failure
Cardiac pain in men - CORRECT ANSWER-center or side chest pain that radiates
to the L arm
Cardiac pain in women - CORRECT ANSWER-reports of feeling sick, fatigue, body
pain, jaw pain, neck/arm pain
