CCRI Nursing 1010 Exam 4- Fluid/Electrolyte/Physical Assessment/Nutrition/Oxygenation & Perfusion
Techniques of Assessment Correct Answer-1. inspection
2. palpation
3. percussion
4. auscultation
Techniques of Assessment (belly) Correct Answer-1. inspect
2. auscultate
3. percuss
4. palpate
Skin check ABCD Correct Answer-Asymmetry
Border Irregularity
Color
Diameter
erythema Correct Answer-redness of the skin
Where should turgor be assessed? Correct Answer-sternum and forearm (sternum/forehead in elderly) clubbing of nails Correct Answer-finding in the nails that indicates chronic hypoxia
capillary refill time Correct Answer-should be less than 3 seconds
What does 20/20 vision mean? Correct Answer-What a person with perfect vision can see at 20 feet, you can also see at 20 feet
what does 20/200 mean? Correct Answer-that at 20 feet the patient can read print that a person of normal vision can read at 200 feet. the larger the second number the worse the vision
optic chiasm Correct Answer-the point at which the optic nerves from the inside half of each eye cross over and then project to the opposite half of the brain
What does PERRLA stand for? Correct Answer-Pupils Equal, Round, Reactive to Light and Acommodation
Average pupil size? Correct Answer-3-5 mm
how to inspect adult ear canal? Correct Answer-pull pina up and back
how to inspect ear canal of child? Correct Answer-pull pina back and down What does the rhinne test for? Correct Answer-bone conduction (against
tmj) air conduction (sideways)
Weber test Correct Answer-hearing test using a tuning fork; distinguishes between conductive and sensorineural hearing loss (on top of head)
What is a bruit? Correct Answer-A bruit is a vascular sound that reflects partial arterial occlusion
vesicular breath sounds Correct Answer-I>E
soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue
Bronchial lung sounds Correct Answer-I=E
heard over trachea; expiratory sound predominates; is higher pitched and
louder; if heard in other locations it indicates consolidation -- a space that usually contains air now has fluid
bronchovesicular breath sounds Correct Answer-I<E
Breath sounds normally heard in the posterior chest between the scapulae and in the center part of the anterior chest in the adult; softer than bronchial sounds; about equal during inspiration and expiration Cardiac Auscultation Correct Answer-stethoscope should be placed over
the mitral valve area, in the left fifth intercostal space over the apex of the heart to hear the first heart sound ("lub").
S2 sound (dub) Correct Answer-Normal closure of aortic/pulmonary valves (end of systole)
S1 sound (lub) Correct Answer-normal closure of mitral and tricuspid valves, beginning of systole
Lung landmarks Correct Answer--Apex : highest point of lung tissue. 3-
4 cm above the inner third of clavicles
-Base: lowest border of lung tissue. Rests on diaphragm. Anterior location at 6th rib in midclavicular line. Laterally at 7th or 8th rib. Posterior location at T 10.
adventitious breath sounds Correct Answer-Abnormal breath sounds such as wheezing, stridor, rhonchi, and crackles.
cardiac landmarks Correct Answer-
Cardiac PMI refers to? Correct Answer-point of maximal intensity
peripheral pulse sites Correct Answer--radial
-carotid
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