N224 Exam 2 – Questions/Answers (100% Accurate) The second heart sound is a result of ✔️Ans - closing of the aortic and
pulmonary valves (semilunar valves) and signals end of systole Pg: 455 and
456 Vital signs normal and capillary refill is 5 seconds, what should nurse do next ✔️Ans - Consider this a delayed capillary refill time and investigate further; normal capillary refill is less than 1-2 seconds; the following conditions can
skew the findings: a cool room, decreased body temperature, cigarette
smoking, peripheral edema, and anemia m
pg:508
Pulse amplitude scale ✔️Ans - 0= absent 1+= weak 2+= normal 3+= Increased, full 4+= bounding
pg: 509
Where is the dorsalis pedis pulse? ✔️Ans - lateral to and parallel with extensor tendon of big toe
pg: 514
Pitting Edema Scale ✔️Ans - 1+ Mild pitting, slight indentation, no perceptible swelling 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains for a short time, leg looks swollen 4+ Very deep pitting, indentation lasts long time, leg very swollen and
distorted Pg:515
To assess for a pulse deficit, you would assess which sites? ✔️Ans - Apical
and radial pulse Pg: 472
If unable to palpate a peripheral pulse, then the next step would be to:
✔️Ans - use a doppler device; used to detect weak peripheral pulses or blood 1 / 3
pressures; the doppler magnifies pulsatile sounds from the heart and blood vessels During assessment of precordium of an adult patient, the nurse palpates the apical impulse at the 6th intercostal space and outside the midclavicular line.This most likely suggests? ✔️Ans - Left ventricular dilation (volume- overload) displaces impulse down and to left and increases size more than one space If apical pulse and radial pulse are not identical (pulse deficit), its most likely do to ✔️Ans - atrial fibrillation, premature beats, and heart failure pg:472 Which is not a modifiable risk factor for cardiovascular disease? ✔️Ans - menopause What are the 9 potentially modifiable risk factors for CVD? ✔️Ans - - abnormal lipids -smoking -hypertension -diabetes
- abdominal obesity
- psychosocial factors
-inadequate consumption of fruits and vegetables -alcohol use -lack of regular physical activity
pg: 462, 465
Vertebra prominens ✔️Ans - spinous process of C7; the most prominent bony spur protruding at the base of the neck . counting ribs and intercostal spaces on the posterior thorax is difficult because of muscles and soft tissue.C7 is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest. The vertebra prominens is not opposite the interior border of the scapula or next to the
manubrium of the sternum Pg: 406
Anterior apices of the lungs ✔️Ans - extend 3-4 cm above the inner third of clavicle; on the posterior chest, the apices are at the level of C7 pg: 407 2 / 3
Correct auscultating technique of lungs ✔️Ans - firmly holding the diaphragm of the stethoscope against the skin of the chest; patient should be instructed to breathe through mouth, a little deeper than usual; diaphragm
should be used Pg: 420
In a patient with history of Chronic Obstructive Pulmonary Disease, what is likely to be seen? ✔️Ans - an anteroposterior-to-transverse diameter ratio
of 1:1 or barrel chest is observed in individuals with COPD bc of
hyperinflation of the lungs; the ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. chest expansion may be decreased but
symmetric. pg: 417 and 433
During auscultation of lungs, ✔️Ans - listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness. The nurse should listen with the diaphragm of the
stethoscope directly onto the patient's skin, not over gown or clothing. pg:420
Where does the trachea bifurcate on the anterior chest? ✔️Ans - sternal angle marks the site of the tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it
lies between T4 and T5 pg: 408
In a patient with severe asthma, air passing through narrowed bronchioles would produce which of these adventitious sounds? ✔️Ans - wheezes; caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.location of apex of heart ✔️Ans - 5th intercostal space location of base of heart ✔️Ans - 3rd intercostal space apex of lungs ✔️Ans - 3-4 cm above inner third of clavicles base of lungs ✔️Ans - rests on the diaphragm systole ✔️Ans - -coincides with S1
- / 3