NUR 255 TEST 1 COMPLETE WITH
CORRECT ANSWERS
Normal breathing sounds - CORRECT ANSWER- Bronchial sounds-
High pitch, over trachea/larynx, sounds hollow/tubular
Bronchovesicular-Moderate Pitch, over major bronchi, sounds mixed
Vesicular-Over peripheral lungs, sounds rustling, like sound of win in the
trees
Tracheal-Loud intensity, high pitch. Harsh;not normally ausculated.
Adventitious sounds - CORRECT ANSWER- These are added
sounds that are NOT normally heard in the lungs.
Adventitious Lung sounds(Crackles-Fine) - CORRECT ANSWER-
Discontinuous, high pitched, short crackling. Popping sounds heard
during inspiration.
Mechanism:Inhaled air collides w/ previously deflated airways, airways
suddenly pop open creating explosive craclking sound.
Late crackles:Occur with restrictive disease
Early crackles: Occur with obstructive disease
Adventitiousl Lung sounds(Crackles-Coarse) - CORRECT ANSWER-
Discontinuous sounds. Loud, low-pitched, bubbling and gurgling sounds
that start in inspiration and may be present in expiration.
Mechanism:Inhaled air collides w/ secretions in the trachea and large
bronchi
Ex:Pulmonary Edema, pneumonia
Adventitious Lung sounds(Wheeze) - CORRECT ANSWER- High
intensity, expiratory sounds. Continuous sounds normally heard on
expiration. Obstruction of airway, can be associated with asthma, CHF,
COPD.
,Adventitiousl Lung sounds(Rhonchi) - CORRECT ANSWER- Loud
intensity, expiratory sounds. Continuous musical sounds similar to
wheezes; imply obstruction of larger airways by secretions
Adventitious Lung sounds(Stridor) - CORRECT ANSWER- High
pitched, monophomic inspiratory. crowing sound, louder in neck than
over chest wall.
Mechanism: originating in larynx or trachea, upper airway obstruction
from swollen, inflamed tissues or lodged foreign bodies.
Ex:Obstructed airway
Abnormal lung sounds(decreased or absent breath sounds) -
CORRECT ANSWER- 1.When the bronchial tree is obstructed at some
point by secretions, mucus plug, or foreign body
2.In emphysema, b/c of loss of elasticity, lungs are already hyperinflated
so the inhaled air does not make much noise
3.When anything obstructs transmission of sound between the lung and
your stethoscope, such as pleural thickening, or air fluid in the pleural
space.
A slilent chest means no air is moving in or out.
S1
S2 - CORRECT ANSWER- S1-Apex(lub) bottom of heart-Occurs w/
closure of the Av(aortic valve) valves and thus signals the beginning of
systole
S2-Base(dub) top of heart-Occurs w/ closure of the semilunar valves &
signals the end of systole
Risk factors for heart disease - CORRECT ANSWER- -Diet
-lack of exercise, lazy lifestyle
-genetics
-High cholesterol
Physical examination: The heart - CORRECT ANSWER- -Inspect
Anterior Chest
-Palpate for a thrill
-Palpate Apical Impulse-PMI(Point of Maximal Inpoint)
, Thrill - CORRECT ANSWER- Vibratory feeling(in physical
examination of heart)
Systole - CORRECT ANSWER- Heart contraction
Diastole - CORRECT ANSWER- Ventricles relax and fill with blood
Extra sounds S3,S4 - CORRECT ANSWER- S3-Ventricular fillings
creates vibrations that can be heard over the chest, when it is usually
silent. occurs b/c ventricles are resistant to filling during early rapid filling
phase
S4-Occurs at end of diastole, when ventricle is resistant to filling. Blood
pushes into noncompliant ventricle
Ausculation of heart sounds - CORRECT ANSWER- S1 is louder at
apex tan S2
S2 is louder at base than S1
S1 coincides with carotid artery pulse
S2 coincides with the Rwave.
Murmur - CORRECT ANSWER- Is a blowing, swooshing sound that
occurs with turbulent blood flow in the heart of great vessels
Murmur grading level - CORRECT ANSWER- Grade I-Barely audible
Grade II-Clearly audible
Grade III-Moderately loud
Grade IV-Loud, associated with a thrill palpable on the chest wall
Grade V-Very loud
Grade VI-Loudest, still heart with entire stethoscope lifted off chest
Normal for heart beat - CORRECT ANSWER- 50-90 BPM, with
regular rythm
Nursing assessment - CORRECT ANSWER- assessment-diagnosis-
planning-intervention-evaluation
ANA standards - CORRECT ANSWER- developed by the American
Nurses association for nursing practice.
CORRECT ANSWERS
Normal breathing sounds - CORRECT ANSWER- Bronchial sounds-
High pitch, over trachea/larynx, sounds hollow/tubular
Bronchovesicular-Moderate Pitch, over major bronchi, sounds mixed
Vesicular-Over peripheral lungs, sounds rustling, like sound of win in the
trees
Tracheal-Loud intensity, high pitch. Harsh;not normally ausculated.
Adventitious sounds - CORRECT ANSWER- These are added
sounds that are NOT normally heard in the lungs.
Adventitious Lung sounds(Crackles-Fine) - CORRECT ANSWER-
Discontinuous, high pitched, short crackling. Popping sounds heard
during inspiration.
Mechanism:Inhaled air collides w/ previously deflated airways, airways
suddenly pop open creating explosive craclking sound.
Late crackles:Occur with restrictive disease
Early crackles: Occur with obstructive disease
Adventitiousl Lung sounds(Crackles-Coarse) - CORRECT ANSWER-
Discontinuous sounds. Loud, low-pitched, bubbling and gurgling sounds
that start in inspiration and may be present in expiration.
Mechanism:Inhaled air collides w/ secretions in the trachea and large
bronchi
Ex:Pulmonary Edema, pneumonia
Adventitious Lung sounds(Wheeze) - CORRECT ANSWER- High
intensity, expiratory sounds. Continuous sounds normally heard on
expiration. Obstruction of airway, can be associated with asthma, CHF,
COPD.
,Adventitiousl Lung sounds(Rhonchi) - CORRECT ANSWER- Loud
intensity, expiratory sounds. Continuous musical sounds similar to
wheezes; imply obstruction of larger airways by secretions
Adventitious Lung sounds(Stridor) - CORRECT ANSWER- High
pitched, monophomic inspiratory. crowing sound, louder in neck than
over chest wall.
Mechanism: originating in larynx or trachea, upper airway obstruction
from swollen, inflamed tissues or lodged foreign bodies.
Ex:Obstructed airway
Abnormal lung sounds(decreased or absent breath sounds) -
CORRECT ANSWER- 1.When the bronchial tree is obstructed at some
point by secretions, mucus plug, or foreign body
2.In emphysema, b/c of loss of elasticity, lungs are already hyperinflated
so the inhaled air does not make much noise
3.When anything obstructs transmission of sound between the lung and
your stethoscope, such as pleural thickening, or air fluid in the pleural
space.
A slilent chest means no air is moving in or out.
S1
S2 - CORRECT ANSWER- S1-Apex(lub) bottom of heart-Occurs w/
closure of the Av(aortic valve) valves and thus signals the beginning of
systole
S2-Base(dub) top of heart-Occurs w/ closure of the semilunar valves &
signals the end of systole
Risk factors for heart disease - CORRECT ANSWER- -Diet
-lack of exercise, lazy lifestyle
-genetics
-High cholesterol
Physical examination: The heart - CORRECT ANSWER- -Inspect
Anterior Chest
-Palpate for a thrill
-Palpate Apical Impulse-PMI(Point of Maximal Inpoint)
, Thrill - CORRECT ANSWER- Vibratory feeling(in physical
examination of heart)
Systole - CORRECT ANSWER- Heart contraction
Diastole - CORRECT ANSWER- Ventricles relax and fill with blood
Extra sounds S3,S4 - CORRECT ANSWER- S3-Ventricular fillings
creates vibrations that can be heard over the chest, when it is usually
silent. occurs b/c ventricles are resistant to filling during early rapid filling
phase
S4-Occurs at end of diastole, when ventricle is resistant to filling. Blood
pushes into noncompliant ventricle
Ausculation of heart sounds - CORRECT ANSWER- S1 is louder at
apex tan S2
S2 is louder at base than S1
S1 coincides with carotid artery pulse
S2 coincides with the Rwave.
Murmur - CORRECT ANSWER- Is a blowing, swooshing sound that
occurs with turbulent blood flow in the heart of great vessels
Murmur grading level - CORRECT ANSWER- Grade I-Barely audible
Grade II-Clearly audible
Grade III-Moderately loud
Grade IV-Loud, associated with a thrill palpable on the chest wall
Grade V-Very loud
Grade VI-Loudest, still heart with entire stethoscope lifted off chest
Normal for heart beat - CORRECT ANSWER- 50-90 BPM, with
regular rythm
Nursing assessment - CORRECT ANSWER- assessment-diagnosis-
planning-intervention-evaluation
ANA standards - CORRECT ANSWER- developed by the American
Nurses association for nursing practice.
