Respiratory
What is regular respiratory rate?
What is 12-20 breaths/min.
What is normal heart rate?
What is 60-100 beats/min.
Name two signs of poor tissue perfusion
What are pain, pallor, cyanosis, cool temperatures, numbness/tingling, hair loss, non healing wounds/ulcerations.
Name 2 S/S of respiratory distress
What are pursed lips, trapezius and sternocleidomastoid use, retractions, stridor, cyanosis, flaring of the nostrils
Where is the apical pulse located?
What is the 5th intercostal space, left midclavicular line.
A nurse presses down on the patient's skin and notices that the skin indents 4 mm and lasts for 10-15 seconds until going back to normal. How would the nurse document this finding?
What is pitting edema +2
These breath sounds are heard through most of the lung fields, have a low-pitch sound, and inspiration is longer than expiration.
What are vesicular breath sounds
This heart sound has a faint low pitched extra heart sound that occurs directly after the S2 heart sound and sounds like a "ventricular gallop" or "Kentucky."
What is S3.
What is the angle measurement in degrees if a patient has clubbing of the nails?
What is an angle >160 degrees.
These respirations have a gradual increase in depth of respiration followed by a gradual decrease, with moments of apnea.
What are Cheyne Stokes respirations.
This is known as an extra sound of the heart or gentle swooshing which is often related to turbulent blood flow in the heart.
What is a murmur.
The nurse pinches a patient's skin and lets go quickly. The skin stays in the pinched position and takes awhile to go back to normal. What is the nurse checking and what is this abnormal finding called?
What are skin turgor and tenting of the skin.
The nurse knows that a 1:1 anteroposterior to transverse ratio is most commonly caused by...
What is COPD.
What causes a pericardial friction rub?
What is inflammation of the pericardial sac surrounding the heart.
Distention of the jugular vein is often see in this condition?
What is congestive heart failure and fluid overload
The nurse is assessing a patient and notices they have a pigeon's chest? What is this condition called and what causes this?
What are pectus carinatum and associated with Acromegaly or Marfan's syndrome.