WorksheetsEXAM 1NUR 204
Total questions: 109
Worksheet time: 2hrs 48mins
Bronchial breath sounds can be auscultated where?
Peripheral lung fields
Sternal area
Mid-scapulae area
Tracheal area
These type of breath sounds are found at the site of the bronchi and are located anteriorly at the 1st and 2nd intercostal space & posteriorly in between the scapulae?
Crackles
Wheezes
Bronchovesicular
Vesicular
These breath sounds are found anteriorly and posteriorly throughout the peripheral lung fields?
High-pitched wheezes
Vesicular
Discontinuous
Bronchial
While assessing a patient's lung sounds you note bronchial breath sounds in the peripheral lung fields. What could this finding represent?
This is a normal finding.
Pulmonary emboli
Lung consolidation like with pneumonia
Pleuritis
Select all of the following that are considered discontinuous breath sounds:
High-pitched wheeze
Stridor
Pleural friction rub
Fine crackles
Coarse Crackles
True or False: Low-pitched wheezes are polyphonic sounds that can be cleared when coughing.
True
False
This lung sound is continuous, high-pitched with musical instrument sound that is polyphonic and occurs mainly during expiration but can be present with inspiration as well?
Stridor
Fine crackles
High-pitched wheeze
High-pitched crackles
On auscultation of a patient in respiratory distress, you hear a high-pitched, harsh sound that is monophonic and is present only during inspiration. This is known as
Stridor
Vesicular
Rales
Rhonchi
You are auscultating a patient's lung sounds. During your assessment, you note there is a low-pitched harsh, grating sound that sounds like a pleural friction rub. However, you're not sure if this is a pleural friction rub or pericardial friction rub. What do you do next to determine the difference?
Have the patient cough and see if the sound clears
Assess the posterior lower lobe only
Have the patient hold their breath and note if the sound is still present
Place the patient in supine position and reassess for the sound
True or False: The left lung has 3 lobes: left upper lobe, left middle lobe, and left lower lobe.
True
False
True or False: During auscultation, the anterior part of the chest mainly provides an assessment of the upper lobes of the right and left lungs, while the posterior part of the chest provides mainly provides an assessment of the lower lobes of the right and left lungs.
True
False
When auscultating the anterior part of the chest, specifically the apex of the lungs, it is best to auscultate where with the stethoscope?
Slightly above the clavicle
2nd intercostal space mid-clavicular
4th intercostal space mid-clavicular
6th intercostal space mid-axillary line
The right middle lobe is auscultated with the stethoscope where?
Posteriorly on the right at the 4th intercostal space
Anteriorly on the right at the 4th intercostal space
Anteriorly between C7 to T3
Posteriorly between T3 to T10
When auscultating the posterior part of the chest the upper lobes are found?
Between C9 to T10
Between T3 to T10
Between C7 to T3
Directly over the scapulae
High-pitched, polyphonic wheeze
Fine Crackles
Stridor
Bronchial
Vesicular
Bronchial
Low-pitched, monophonic wheeze
Fine Crackles
Rales
Stridor
Bronchovesicular
Pleural Friction Rub
Stridor
Vesicular
Coarse Crackles
Bronchial
Low-pitched, monophonic wheeze
High-pitched, monophonic wheeze
Vesicular
Bronchial
Bronchial
Low-pitched, monophonic wheeze
Bronchovesicular
Pleural Friction Rub
Stridor
Pleural Friction Rub
Vesicular
Low-pitched, monophonic wheeze
Fine Crackles
Bronchovesicular
Coarse Crackles
Pleural Friction Rub
Coarse Crackles
Bronchial
Low-pitched, monophonic wheeze
Stridor
The nurse is auscultating a patient's heart sounds. Which area is best for hearing the sound of the mitral valve?
Fifth left intercostal space at the midclavicular line
Second left intercostal space at the sternal border
Fourth left intercostal space at the left sternal border
Second right intercostal space at the sternal border
Which conditions may cause a pathologic S3, or a ventricular gallop? Select all that apply.
Anemia
Pregnancy
Hyperthyroidism
Cardiomyopathy
What is indicated in a patient with pathologic S3?
A stenotic heart valve
Coronary artery disease
Vigorous atrial contraction
Decreased compliance of the ventricles
What are chordae tendineae?
These are muscles that are attached to the ventricles.
These are tendons that hold the semilunar valves in alignment.
These are structures that separate the right and the left ventricles.
These are collagenous fibers that anchor the leaflets of the atrioventricular valves.
The nurse is preparing a patient for cardiac assessment. Which interventions should the nurse follow while assessing?
Compress on the carotid artery during the assessment.
Have the patient sit during the carotid artery assessment.
Put the patient in a supine position to assess the precordium.
Maintain a warm room temperature during cardiac assessment.
Assess the neck vessels first during the cardiovascular assessment.
Which findings should the nurse observe in a patient with left ventricular hypertrophy?
. Visible apical heave
Change in heart location
Impalpable apical impulse
Diameter of the heart 3.5 cm
Higher jugular venous pressure
While assessing a patient with pulmonic stenosis, the nurse hears medium pitched murmurs in the left second intercostal space. Which finding does the nurse observe in the patient?
Accentuated S 1
Fixed split S 2
Pathologic S 3
Pathologic S 4
The nurse determines that a patient has an increased risk for having a myocardial infarction. Which medication would be beneficial for the patient?
Aspirin (Ecotrin)
Ibuprofen (Advil)
Diclofenac (Cambia)
Acetaminophen (Apra)
The patient reports having a sudden stabbing pain below the sternum, in the upper back, and in the neck. During the assessment, the nurse also finds that the patient has a fever, joint pains, and a dry cough. What condition is most consistent with these findings?
Pericarditis
Angina pectoris
Myocardial infarction
Pulmonary hypertension
Which heart rate would be found in an infant with bradycardia?
50 beats/minute
70 beats/minute
80 beats/minute
90beats/minute
The nurse is caring for a patient who has an incompetent tricuspid valve. Where should the nurse observe the palpable thrill in this patient?
Fifth interspace at around the left midclavicular line
Second left interspace
Second right interspace
Left lower sternal border
Which assessment finding indicates abnormally elevated pressures in the right side of the heart?
Pulmonary congestion
Pulmonary hypertension
distended neck veins and abdomen
systolic blood pressure higher than diastolic blood pressure
Which statement describes a thrill
Palpable vibration in the chest
Apical impulse
Associated with a venous hum
Sustained thrust of the ventricle of the heart
The nurse is planning the cardiac assessment of a patient. Which patient positions are necessary during this assessment?
Sitting
Prone
Supine
Right lateral semi-Fowler
Left lateral recumbent
Which physiologic mechanism causes the first heart sound
closing of the mitral valve
Filling of the ventricle
Closing of the aortic valve
Closing of the pulmonic valve
Which cardiac assessment findings are documented as normal? select all that apply
Absence of cardiac murmur
S2 is louder at the base of the heart
Accentuated first heart sound S1
Diminished second heart sound S2
Absence of equal and bilateral breath sounds
Which feature is characteristic of the third heart sound S3
Varies with inspiration
Sound pitch remains the same
Occurs in the second left interspace
Occurs at the left lower sternal border
The nurse is preparing a patient for cardiac assessment. Which interventions should the nurse follow while assessing?
Compress on the carotid artery during the assessment
Have the patient sit during the carotid artery assessment.
Put the patient in a supine position to assess the precordium.
Maintain a warm room temperature during cardiac assessment
Assess the neck vessels first during the cardiovascular assessment.
Which assessment finding may be present in a patient with atherosclerosis
low-pitched rumbling
presence of bruit sound
weak contraction of the ventricles
unilateral distention of external jugular veins
The accumulation of lymph in the breasts and upper arms is a results of an obstruction of which lymph nodes
Cervical
Axillary
Inguinal
Epitrochlear
The nurse documents the pulse of the patient as weak 1+. Which conditions in the patient correlate with a weak and thready 1+ pulse?
shock
fever
Anemia
Peripheral artery disease
After measuring pitting edema in a patient, the nurse documents it as +4 grade. Which findings support the nurse's documentation?
The patient has very deep pitting.
The patient has grossly swollen legs.
The patient has indentation of long duration.
The patient has moderate pitting
The patient has indentation of short duration
Which class of medications would be most beneficial for a bedridden patient who reports sudden sharp pain the legs, which upon assessment are found to be warm, red, and edematous
Analgesics
Antibiotics
Anticoagulants
Antihypertensive
Which statement describes a lift with respect to the cardiovascular system?
Vibration felt over the apex of the heart
Sustained thrust of the ventricle of the heart
Exaggerated pulse felt on the carotid artery
Murmur over the second right intercostal space during diastole
The nurse instructs a student nurse to palpate the carotid artery of a patient. Which action made by the student nurse needs correction?
Having the patient sit during the exam
Palpating both carotid arteries at once
Refraining from excess vagal stimulation
Not compressing on the carotid sinuses
When performing indirect percussion, the stationery finger is struck:
At the ulnar surface
At the middle joint
At the distal interphalangeal joint
Wherever it is in contact with the skin
The bell of the stethoscope is used:
For soft, low-pitched sounds
For high pitched sounds
To hold firmly against the skin
To magnify sound
To assess a patient's abdomen by palpation, how should the nurse proceed?
Avoid palpation of reported "tender" areas because this may cause the patient pain
Quickly palpate a tender area to avoid any discomfort that the patient may experience
Begin the assessment with deep palpation, encouring the patient to relax and take deep breaths
Start with light palpation to detect surface characteristics and to accustom the patient to being touched
Please select correct statement on how to use diaphragm (Select all that apply.)
It is best for high-pitched sounds.
It is for breath, bowel, and normal heart sounds.
It is for extra heart sounds or murmurs.
The nurse will hold the diaphragm firmly against the person's skin, firm enough to leave a slight ring afterward.
The nurse will hold the diaphragm lightly against the person's skin, just enough that it forms a perfect seal.
What percussion sound would a nurse hear when percussing over normal lung tissue?
Resonant
Tympany
Dull
Flatt
A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following?
Hyperresonance
Tympany
Resonance
Dullness
In crease respiration in both rate and depth. It occurs with anxiety, diabetic ketoacidosis (Kussmaul respirations).
Hyperventilation
Tachypnea
Biot respiration
Bradypnea
Cheyne-stokes respiration
Rapid, shallow breathing, increased rate > 24 per minute.
Hyperventilation
Tachypnea
Biot respiration
Bradypnea
An irregular patterns of a series of normal respiration followed by a period of apnea; It may occur with head trauma or encephalitis.
Biot respiration
Hyperventilation
Tachypnea
Bradypnea
Cheyne-stokes respiration
An irregular slow and shallow breathing pattern caused by an overdose of narcotics.
Biot respiration
Bradypnea
Cheyne-Stokes respiration
Hypoventilation
Tachypnea
Croup and acute epiglottitis, obstructed airway.
Stridor
Crackles
Wheeze
Rhonchi
Pleural friction rub
Discontinuous, high-pitched, short crackling, popping sounds during inspiration, not cleared by coughing
Crackles
Stridor
Wheezing
Rhonchi
pleural friction
Coarse and low pitched with a grating quality as if two pieces of leather are being rubbed together
Pleural friction
crackles
stridor
Wheezing
Secretions in larger airways.
Crackles
pleural friction rub
Wheezing
Rhonchi
Stridor
High-pitched, musical squeaking sounds predominantly in expiration;
Wheeze
Stridor
Pleural Friction
Rhonchi
crackles
Low-pitched with musical snoring quality, more prominent on expiration.
rhonchi
wheezing
crackles
stridor
pleural friction
High-pitched, inspiratory, crowing sound
Rhonchi
Wheeze
Stridor
Pleural friction
In egophony, you should hear "aaaaaa" sound in healthy person's lungs.
True
False
What type of respiratory pattern would the nurse consider normal in a client with severe heart failure?
Cheyene-stokes
Kussmaul's
Bradypnea
Biot's
When percussing the scapula of a patient, which of the following would the nurse expect to hear?
Resonance
Dullness
Flatness
Hyperresonance
During a health history, a male patient tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this patient further for which of the following?
Pneumonia
Tuberculosis
Bronchitis
Heart failure
What would the nurse expect to hear when auscultating the lungs of a patient with pleuritis?
Friction rub
Decreased breath sounds
Sibilant wheeze
stridor
When assessing whispered pectoriloquy, the nurse would instruct a patient to do which of the following?
Softly repeat the words "one-two-three"
Say "ninety-nine"
Cough each time the stethoscope is moved
Say the letter "e"
Changes in clarity and volume of spoken sounds during auscultation of the lungs can help you distinguish
right from left tracheal deviation
foreign body from mucus
pulmonary edema from pleurisy
consolidation from obstruction
Which of the following would be best for a nurse to use when assessing for fremitus in a client?
Dorsal hand surface
Pads of fingers
Palmar base (ulnar base)
Fist
Select decreased breath sounds in the following common lung diseases (Select all that apply.)
Emphysema: permanent enlargement of air sacs distal to terminal bronchioles and rupture of interalveolar walls due to destruction of pulmonary connective tissue
Heart failure: increased pressure in the pulmonary veins causes congestion and interstitial edema
Pleural effusion: fluid accumulates in the pleural space and separates air-filled lung from the chest wall.
Pneumothorax: when air leaks into the pleural space, partial or complete lung collapse
Atelectasis (Lobar obstruction): when a plug in a mainstem bronchus obstructs air flow, affected lung tissue collapses into an airless state
Please select the normal lung assessment technique
When assessment chest expansion, place your hands on the posterolateral chest wall with thumbs pointing together at the level of T5 or T6.
When examining for tactile fremitus, it is important to palpate the chest symmetrically.
In percussion, start percussing at the base.
Auscultate the lung fields over the anterior chest from the apices in the supraclavicular ares down to the 6th rib.
Inspection includes chest shape and configuration, person's position, skin color, breathing effort, and level of consciousness.
Normal respirate rate for adult is 10-20 breaths per minute.
True
False
Dullness to percussion in intercostal spaces suggests the presence of: (select all that apply.)
Emphysema: permanent enlargement of air sacs distal to terminal bronchioles and rupture of interalveolar walls due to destruction of pulmonary connective tissue
Lobar pneumonia: alveoli fill with fluid or blood cells as in pneumonia, pulmonary edema
Atelectasis (Lobar obstruction): when a plug in a mainstem bronchus obstructs air flow, affected lung tissue collapses into an airless state
Chronic bronchitis: the bronchi are chronically inflamed and a productive cough is present
Pleural effusion: fluid accumulates in the pleural space and separates air-filled lung from the chest wall.
A nurse asks a patient to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?
Fremitus
Egophony
Chest expansion
Bronchophony
Heard from trachea and laynx.
Bronchial
Vesicular
Bronchovesicular
pleura
Expiration is longer than inspiration
Bronchial
Vesicular
Bronchovesicular
Pleural
Inspiration is longer than expiration.
Bronchial
Vesicular
Bronchovesicular
Pleura
Over major bronchi where fewer alveoli are located: posterior, between scapulae; anterior around upper sternum in first and second intercostal spaces.
Bronchial
Vesicular
Bronchovesicular
Pleural
Low pitch and soft amplitude.
Bronchial
Vesicular
Bronchovesicular
Pleural
Over peripheral lung fields where air flows through smaller bronchioes and alveoli.
Bronchial
Vesicular
Bronchovesicular
Pleural
defect or sac formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect
aneurysm
ascites
borborygmi
bruit
Please select INCORRECT statement about split S2.
A split S2 occurs toward the end of inspiration in some people.
In split S2, the aortic valve closes slightly before the pulmonic valve toward the end of the inspiration.
A split S2 is heard only in the aortic valve area, the second right interspace.
The split S2 occurs because inspiration separates the timing of the aortic and pulmonic valve's closures due to the effects of respiration on heart.
A pathologic S4 (artrial gallop) occurs with coronary artery disease (CAD) or cardiomyopathy.
True
False
A pathologic S3 (Ventricular gallop) occurs with heart failure and volume overload.
True
False
The nurse notices that the heart rate is irregular. What is the next step?
Listen for extra heart sounds.
Listen for murmurs.
Auscultate all auscultatory areas.
Check for a pulse deficit.
The examiner is palpating the apical impulse. Which is a normal-sized impulse?
Less than 1 cm
Approximately 1x 2 cm
3 cm
Varies depending on the size of the person
You'll hear a split S2 most clearly in what area?
Right 2nd inter costal space
Left second inter costal space
Left sternal border
Left 5th inter costal space at midclavicular line
The second heart sound is the result of: __________ of the _______ valve and _____ valve.
(a)
The heart's filling phase
Apex
Systole
Diastole
Ventricle
Blowing, swooshing sound heard through a stethoscope when an artery is partially occluded
S4
Apical impulse
Bruit
Vetnricular hypertrophy
A heart sound that is very soft, low-pitched, ventricular filling sound that occurs in late diastole; heard immediately before S1
S4
Bruit
Apical impulse
Vetnricular hypertrophy
Pulsation created as the left ventricle rotates against the chest wall during systole, normally at the 5th left intercostal space in the midclavicular line
Apical impulse
S4
Bruit
Vetnricular hypertrophy
Increase in thickness of myocardial wall that occurs when the heart pumps against chronic outflow obstruction
Thrill
Vetnricular hypertrophy
Apical impulse
S4
Palpable vibration on the chest wall accompanying severe heart murmur
Vetnricular hypertrophy
Apical impulse
Thrill
Tachycardia
Rapid heart rate, >100 beats per minute in the adult
Thrill
Vetnricular hypertrophy
Tachycardia
Apical impulse
Tip of the heart pointing down toward the 5th left intercostal space
Mitral valve
Bicuspid valve
Tricuspid valve
Apex
Uncomfortable awareness of rapid or irregular heart rate
palpitation
anxiety
S3
heart failure
A heart sound that is soft, low-pitched, ventricular filling sound that occurs in early diastole and may be an early sign of heart failure; heard right after S2.
S1
S2
S3
S4
A heart sound that occurs with closure of the atrioventricular (AV) valves signaling the beginning of systole
s1
s2
s3
s4
Flat endpiece of the stethoscope used for hearing relatively high-pitched heart sounds
Bell
Diaphragm
Pods
mic
Atrial fibrillation
Normal S1 & S2
Tachycardia
Atrial flutter
Bradycardia
S3
Normal S1 & S2
S4
Premature contractions
S3
Normal S1& S2
S4
Premature contractions
Ventricular fibrillation
MURMUR Mitral Regurgitation
MURMUR Aortic Stenosis
Atrial fibrillation
Atrial fibrillation
MURMUR: Aortic Stenosis
MURMUR: Mitral Regurgitation
Atrial flutter
