NURS 258 test one Questions With Complete Solutions
abnormal lung sounds Correct Answer -
decreased/diminished: hard to hear movement
caused by: pneumonia(infection), emphysema(damaged alveoli),
asthma(narrows airway), PE(extra fluid in pleural space- trauma
or infection)
-absent: do not hear any air movement
caused by: fluid in intapleural space(PE), lung
collapse(pneumothorax)
-crackles (rales): wet sound. fluid in smaller airways, fine(soft
crackling or popping), coarse(loud bubbling or gurgling), does
not clear with coughing, most common in bases of lungs,
caused by: CHF, COPD, pneumonia
-wheezes- sounds like a whale. whistling or sighing sound,
inflammation in airway. narrowing of airway.
caused by: asthma, COPD, croup, RSV(respiratory syncytial
virus), allergic reaction
-stridor: gasping inspiration, high pitched brassy, heard on
inspiration, laryngeal edema, more pronounced in
children(smaller airways)
caused by: croup(barking cough "seal bark"), epiglottis,
obstruction from foreign body
-rhonchi: coarse breath sounds(snoring)
caused by: chronic mucus in bronchial airway
airborne infection Correct Answer TB- respirator
auscultation Correct Answer sitting up
do not listen over clothing
deep breaths in and out of mouth
, listen each area for 1 full breath
compare left to right
6 anterior and 8 posterior(includes laterals)
blood pressure Correct Answer average for age
factors influencing: agre, stress, ethnicity, meds, activity and
weight, smoking
equipment: correct bp fuff size, stethoscope, electronic bp
machine
estimated systolic: bp too low, cant estimate dnp
sites: upper arm, wrist thigh ankle
documenting: manual- identify site
typically no bp until age 3
character of pule Correct Answer rate- tachy <120bpm, brady
<60bpm, factors influencing
rhythm: regular, irregular
strength, 0, -1, -2, -3, -4, equality
peds
common forms nurses document on Correct Answer
admission/nursing history form- admit note/chief complaint
narrative in nurses note
flow sheets/graphic records-vitals, I/o, ADL, assessments
kardex/summary sheet- use for report
care plan notes- outcomes, if met/unmet, need to be changed
transfer/discharge forms: transfer/discharge narrative in nurses
note
teaching notes
nurses notes- short narrative format for deviation/ changes
abnormal lung sounds Correct Answer -
decreased/diminished: hard to hear movement
caused by: pneumonia(infection), emphysema(damaged alveoli),
asthma(narrows airway), PE(extra fluid in pleural space- trauma
or infection)
-absent: do not hear any air movement
caused by: fluid in intapleural space(PE), lung
collapse(pneumothorax)
-crackles (rales): wet sound. fluid in smaller airways, fine(soft
crackling or popping), coarse(loud bubbling or gurgling), does
not clear with coughing, most common in bases of lungs,
caused by: CHF, COPD, pneumonia
-wheezes- sounds like a whale. whistling or sighing sound,
inflammation in airway. narrowing of airway.
caused by: asthma, COPD, croup, RSV(respiratory syncytial
virus), allergic reaction
-stridor: gasping inspiration, high pitched brassy, heard on
inspiration, laryngeal edema, more pronounced in
children(smaller airways)
caused by: croup(barking cough "seal bark"), epiglottis,
obstruction from foreign body
-rhonchi: coarse breath sounds(snoring)
caused by: chronic mucus in bronchial airway
airborne infection Correct Answer TB- respirator
auscultation Correct Answer sitting up
do not listen over clothing
deep breaths in and out of mouth
, listen each area for 1 full breath
compare left to right
6 anterior and 8 posterior(includes laterals)
blood pressure Correct Answer average for age
factors influencing: agre, stress, ethnicity, meds, activity and
weight, smoking
equipment: correct bp fuff size, stethoscope, electronic bp
machine
estimated systolic: bp too low, cant estimate dnp
sites: upper arm, wrist thigh ankle
documenting: manual- identify site
typically no bp until age 3
character of pule Correct Answer rate- tachy <120bpm, brady
<60bpm, factors influencing
rhythm: regular, irregular
strength, 0, -1, -2, -3, -4, equality
peds
common forms nurses document on Correct Answer
admission/nursing history form- admit note/chief complaint
narrative in nurses note
flow sheets/graphic records-vitals, I/o, ADL, assessments
kardex/summary sheet- use for report
care plan notes- outcomes, if met/unmet, need to be changed
transfer/discharge forms: transfer/discharge narrative in nurses
note
teaching notes
nurses notes- short narrative format for deviation/ changes
