NUR 211 EXAM 1 AND ANSWERS
ABGs - answer-invasive way to measure oxygen saturation (and other values) 80-100 mm Hg
abnormal PVS auscultation - answer-BP: lying, sitting, standing-- >20 mmHg is postural/orthostatic
hypotension, auscultate for bruits (blowing/swishing sound caused by turbulence because of narrowed
lumen, use bell of stethoscope, palpate for a "thrill")
accountability - answer-being held to answer for personal actions and actions of others
acute insomnia - answer-lasts one to several nights and is often caused by PERSONAL stressors and/or
worry
adventitious breath sounds - answer-crackles/rales, rhonchi/gurgles, wheezes, stridor, pleural friction
rub
adventitious heart sounds - answer-gallop, murmur, pericardial friction rub, click
afterload - answer-pressure which the left ventricle pushes against
ambulation - answer-immobility is major factor in developing atelectasis and ventilator associated
pneumonia, early ambulation improves lung expansion, dangle and stand intubated patients, get
patients out of bed ASAP (day of surgery)
angina pectoris - answer-chest pain related to inadequate oxygen supply (ischemia)
arterial insufficiency - answer-usually secondary to atherosclerosis (smoking, increased BP, diabetes),
occlusion (blockage or closing of a blood vessel), vasospasm (sudden constriction of blood vessel),
ulcerations
arteriosclerosis - answer-elastic and muscular tissues of the arteries are replaced with fibrous tissue
artificial airways - answer-oral airway, endotracheal/tracheal airways, and tracheostomy
assess - answer-assess pain and intensity every 2 hours and PRN, assess skin every 12 hours, assess
before you implement!!
assessing carotid for bruits - answer-vessel most commonly assessed for bruits, ask to turn head away
and possibly hold breath for a few seconds, usually loudest in upper one third of neck, fairly common in
elderly, at risk for stroke
assessment - answer-what is normal for the patient? past impairments in circulatory or respiratory
functioning? methods to optimize oxygenation? food and drug allergies? physical examination?
laboratory and diagnostic tests?
assessment techniques - answer-heart rate/heart sounds, blood pressure, breath sounds, presence of
edema
,atelectasis - answer-collapse of the alveoli that prevents the normal exchange of oxygen and carbon
dioxide
atherosclerosis - answer-build up of fatty plaque in arteries
authority - answer-ability or legitimate power to make decisions, implement strategies, or elicit work
from others
autonomy - answer-right to make one's own decisions
barriers to time management - answer-procrastination, perfectionism, and inability to prioritize
basic concepts - answer-oxygen-rich blood enters the heart from the lungs and goes out to the body
while oxygen-poor blood enters the heart from the body and goes out to the lungs
beneficence - answer-doing good
benefits of sleep - answer-helps people cope with daily stressors, prevents fatigue, conserves energy,
facilitates healing of damaged tissue/wounds, restores mind and body
best practices - answer-start each intervention with an action verb, individualize your interventions to
your client!
BiPAP - answer-provides inspiratory positive airway pressure AND expiratory airway pressure, used to
prevent ET tube in patients with respiratory failure, pulmonary edema, and exacerbation of COPD
blood pressure measurement - answer-rest 5 minutes, wait 1 minute between readings, take the highest
reading if arms differ, watch for patterns rather than a single reading, cuff width should be about 40% of
arm circumference, support arm and level of heart, do not take over clothes
blood pressure monitoring - answer-annual screenings beginning at age 3, average of 2 or more readings
at 2 or more visits after initial screening, typically no symptoms
cardiac output (CO) - answer-amount of blood ejected from the heart each MINUTE
cardiogenic - answer-result of heart failure, semi- or high-fowler's position
cardiovascular - answer-transfer slowly
cardiovascular changes - answer-orthostatic hypotension, thrombosis formation (damage to vessel wall,
alterations in blood flow, alterations in blood constituents)
central apnea - answer-involves a deficit in the respiratory center of the brain
chest physiotherapy - answer-mobilizes and drains secretions from gravity dependent areas of the lung,
three components: chest percussion, vibration, postural drainage
, chest tube care - answer-keep the system closed and below the chest, monitor for air leaks, monitor
chest fluid drainage, encourage TCDB and IS
chronic signs of hypoxia? - answer-clubbed fingers, barrel chest
chronic-intermittent insomnia - answer-difficulty sleeping for a few nights, followed by a few nights of
adequate sleep before the problem returns
circadian synchronization - answer-biological clock coincides with the sleep/wake cycles, person is
awake when body temperature is the highest and asleep when body temperature is the lowest
classification of BP in adults - answer-normal: <120 and <80
prehypertension: 120-139 or 80-89
HTN stage 1: 140-159 or 90-99
HTN stage 2: >160 or >100
click - answer-prosthetic valve
collaborate - answer-think about other multidisciplinary teams you can work with to help the patient--if
you do not have a collaborative intervention, you may use two implementations
complete blood count (CBC) - answer-also called H&H (hemoglobin and hematocrit)
compliance with NPSGs ensures... - answer-quality and safe care for patients
complications of oxygen therapy - answer-drying effects of respiratory mucosa, oxygen toxicity, supports
combustion, skin breakdown
conditions affecting chest wall movement - answer-pregnancy, obesity, neuromuscular disease,
musculoskeletal abnormalities, trauma, CNS alterations
congestive heart failure (CHF) - answer-the heart in inadequate as a pump, decreased cardiac output,
heart can't pump enough blood to support body's metabolic needs
coughing - answer-every 2 hours while awake for patients with respiratory conditions and postop,
patients with large amounts of secretions cough every hour while awake and every 2-3 hours at night
CPAP - answer-continuous positive airway pressure--a nasal device that is used at the client's sleep time
to help maintain an open airway
CPAP - answer-used for sleep apnea or heart failure, positive pressure keeps airway from collapsing
crackles/rales - answer-short, discreet interrupted, crackling sound classified as fine to coarse, caused by
air passing through secretions, moisture (key sound in pneumonia)
cuffed trach (shiley) - answer-purpose of cuff is to create a snug fit in the trachea, helps prevent
aspiration and helps ventilator give stronger breaths
ABGs - answer-invasive way to measure oxygen saturation (and other values) 80-100 mm Hg
abnormal PVS auscultation - answer-BP: lying, sitting, standing-- >20 mmHg is postural/orthostatic
hypotension, auscultate for bruits (blowing/swishing sound caused by turbulence because of narrowed
lumen, use bell of stethoscope, palpate for a "thrill")
accountability - answer-being held to answer for personal actions and actions of others
acute insomnia - answer-lasts one to several nights and is often caused by PERSONAL stressors and/or
worry
adventitious breath sounds - answer-crackles/rales, rhonchi/gurgles, wheezes, stridor, pleural friction
rub
adventitious heart sounds - answer-gallop, murmur, pericardial friction rub, click
afterload - answer-pressure which the left ventricle pushes against
ambulation - answer-immobility is major factor in developing atelectasis and ventilator associated
pneumonia, early ambulation improves lung expansion, dangle and stand intubated patients, get
patients out of bed ASAP (day of surgery)
angina pectoris - answer-chest pain related to inadequate oxygen supply (ischemia)
arterial insufficiency - answer-usually secondary to atherosclerosis (smoking, increased BP, diabetes),
occlusion (blockage or closing of a blood vessel), vasospasm (sudden constriction of blood vessel),
ulcerations
arteriosclerosis - answer-elastic and muscular tissues of the arteries are replaced with fibrous tissue
artificial airways - answer-oral airway, endotracheal/tracheal airways, and tracheostomy
assess - answer-assess pain and intensity every 2 hours and PRN, assess skin every 12 hours, assess
before you implement!!
assessing carotid for bruits - answer-vessel most commonly assessed for bruits, ask to turn head away
and possibly hold breath for a few seconds, usually loudest in upper one third of neck, fairly common in
elderly, at risk for stroke
assessment - answer-what is normal for the patient? past impairments in circulatory or respiratory
functioning? methods to optimize oxygenation? food and drug allergies? physical examination?
laboratory and diagnostic tests?
assessment techniques - answer-heart rate/heart sounds, blood pressure, breath sounds, presence of
edema
,atelectasis - answer-collapse of the alveoli that prevents the normal exchange of oxygen and carbon
dioxide
atherosclerosis - answer-build up of fatty plaque in arteries
authority - answer-ability or legitimate power to make decisions, implement strategies, or elicit work
from others
autonomy - answer-right to make one's own decisions
barriers to time management - answer-procrastination, perfectionism, and inability to prioritize
basic concepts - answer-oxygen-rich blood enters the heart from the lungs and goes out to the body
while oxygen-poor blood enters the heart from the body and goes out to the lungs
beneficence - answer-doing good
benefits of sleep - answer-helps people cope with daily stressors, prevents fatigue, conserves energy,
facilitates healing of damaged tissue/wounds, restores mind and body
best practices - answer-start each intervention with an action verb, individualize your interventions to
your client!
BiPAP - answer-provides inspiratory positive airway pressure AND expiratory airway pressure, used to
prevent ET tube in patients with respiratory failure, pulmonary edema, and exacerbation of COPD
blood pressure measurement - answer-rest 5 minutes, wait 1 minute between readings, take the highest
reading if arms differ, watch for patterns rather than a single reading, cuff width should be about 40% of
arm circumference, support arm and level of heart, do not take over clothes
blood pressure monitoring - answer-annual screenings beginning at age 3, average of 2 or more readings
at 2 or more visits after initial screening, typically no symptoms
cardiac output (CO) - answer-amount of blood ejected from the heart each MINUTE
cardiogenic - answer-result of heart failure, semi- or high-fowler's position
cardiovascular - answer-transfer slowly
cardiovascular changes - answer-orthostatic hypotension, thrombosis formation (damage to vessel wall,
alterations in blood flow, alterations in blood constituents)
central apnea - answer-involves a deficit in the respiratory center of the brain
chest physiotherapy - answer-mobilizes and drains secretions from gravity dependent areas of the lung,
three components: chest percussion, vibration, postural drainage
, chest tube care - answer-keep the system closed and below the chest, monitor for air leaks, monitor
chest fluid drainage, encourage TCDB and IS
chronic signs of hypoxia? - answer-clubbed fingers, barrel chest
chronic-intermittent insomnia - answer-difficulty sleeping for a few nights, followed by a few nights of
adequate sleep before the problem returns
circadian synchronization - answer-biological clock coincides with the sleep/wake cycles, person is
awake when body temperature is the highest and asleep when body temperature is the lowest
classification of BP in adults - answer-normal: <120 and <80
prehypertension: 120-139 or 80-89
HTN stage 1: 140-159 or 90-99
HTN stage 2: >160 or >100
click - answer-prosthetic valve
collaborate - answer-think about other multidisciplinary teams you can work with to help the patient--if
you do not have a collaborative intervention, you may use two implementations
complete blood count (CBC) - answer-also called H&H (hemoglobin and hematocrit)
compliance with NPSGs ensures... - answer-quality and safe care for patients
complications of oxygen therapy - answer-drying effects of respiratory mucosa, oxygen toxicity, supports
combustion, skin breakdown
conditions affecting chest wall movement - answer-pregnancy, obesity, neuromuscular disease,
musculoskeletal abnormalities, trauma, CNS alterations
congestive heart failure (CHF) - answer-the heart in inadequate as a pump, decreased cardiac output,
heart can't pump enough blood to support body's metabolic needs
coughing - answer-every 2 hours while awake for patients with respiratory conditions and postop,
patients with large amounts of secretions cough every hour while awake and every 2-3 hours at night
CPAP - answer-continuous positive airway pressure--a nasal device that is used at the client's sleep time
to help maintain an open airway
CPAP - answer-used for sleep apnea or heart failure, positive pressure keeps airway from collapsing
crackles/rales - answer-short, discreet interrupted, crackling sound classified as fine to coarse, caused by
air passing through secretions, moisture (key sound in pneumonia)
cuffed trach (shiley) - answer-purpose of cuff is to create a snug fit in the trachea, helps prevent
aspiration and helps ventilator give stronger breaths
