Cardiovascular
The location for auscultating the aortic valve
Right sternal border, 2nd intercostal space (ICS)
Sounds that are heard in the middle lobe are found in this lung
Right lung
A client asks why the nurse is listening to bowel sounds before touching the abdomen. What is the best response?
Palpation can alter bowel sounds
A client correctly states their name, location, and today's date. How would the nurse document this level of orientation?
Alert and oriented to person, place, time
This mnemonic is known as PERRLA
Pupils are equal, round, reactive to light and accommodation
Which finding requires follow-up?
Capillary refill 2 seconds
Radial pulses 2+ bilaterally
Unilateral calf swelling
Warm hands
Unilateral calf swelling
Which assessment finding is the priority?
Alert and oriented ×3
Capillary refill 2 seconds
Oxygen saturation 88%
Warm, dry skin
Oxygen Saturation 88%
You would document bowel sounds as hyperactive if you hear this many sounds
Hyperperistalsis: 2-3 sounds per second or over 30 sounds per minute
The nurse notes that a client responds slowly and requires repeated questions to answer appropriately. This change should prompt further assessment of
Level of consciousness (LOC)
This is an abnormally small head size in infants
Microcephaly
The nurse notes absent pedal pulses and a pale, cool foot. This finding suggests
Poor perfusion
A client with chronic obstructive pulmonary disease (COPD) may have this presentation of the chest
Barrel chest (increase of the antero-posterior diameter)
The stomach is found in this quadrant of the abdomen
Left upper quadrant (LUQ)
Known as a rapid, involuntary response that occurs at the level of the spinal cord
Reflex
While inspecting a client's posture from the side, the nurse observes excessive curvature of the thoracic spine. How should this finding be documented?
Kyposis
The nurse documents a pulse as 4+. How would this be documented?
Bounding pulse
A client with reduced airflow may have these breath sounds
Diminished
This presents as bulging near the umbilicus
Umbilical hernia
This part of the brain helps coordinate muscle movement, regulates muscle tone, and maintains posture and equilibrium
Cerebellum
The nurse observes yellow discoloration of the sclera. What finding should be documented?
Jaundice
The nurse notes a jugular vein that remains visibly distended when the client is positioned at 45°. What is this finding?
JVD
This abnormal lung sound is caused by air bubbling through moisture in alveoli
Crackles
This is how long you must auscultate to determine bowel sounds are absent
5 minutes
The scale used to grade eye, motor, and verbal responses
Glasgow coma scale
During inspection, the nurse notes unequal pupil size. This abnormal finding is called
Anisocoria