Respiratory Rundown
This adventitious lung sound resembles popping or crackling and is often heard with fluid in the alveoli.
What are crackles (rales)?
This heart sound is created by the closure of the mitral and tricuspid valves.
What is S1?
What does GCS stand for?
What is the Glasgow Coma Scale?
(Eye, Motor, Verbal)
What does is check for?
What does ROM stand for?
What is Range of Motion?
What does PERRLA stand for?
What is Pupils Equal, Round, Reactive to Light and Accommodation?
This position optimizes airway access and lung expansion during suctioning.
What is semi-Fowler’s or high Fowler’s?
The oxygen flowmeter should always be checked to ensure this is actively happening.
What is the ball is floating and oxygen is flowing?
What are two patient positions used during a respiratory assessment?
What are sitting upright and semi-Fowler's?
What is the anatomical location for auscultating the apical pulse?
What is the 5th intercostal space, midclavicular line?
Name three components of a basic Level of Orientation assessment.
What are orientation to person, place, time, and situation?
This scale is used to assess muscle strength.
What is the 0–5 Muscle Strength Scale?
0 = no movement or contraction
1 = slight contraction - severe weakness
2 = Passive ROM, can't lift against gravity
3 = Active ROM, can lift against gravity, can not overcome resistance
4 = Active ROM, can lift against gravity and overcome some resistance - slight weakness
5 = Active ROM, lift against gravity and overcome full resistance - normal
What test checks for peripheral vision?
What is the Confrontation test?
The sterile, removable inner portion of the tracheostomy tube.
What is the inner cannula?
The maximum flow rate for a nasal cannula in L/min.
What is 6 L/min?
What does the term "CMST" stand for?
What is Color/circulation, Movement, Sensation, and Temperature?
This scale is used to grade the strength of peripheral pulses.
What is the Pulse Amplitude Scale?
0: Absent Pulse
1+ Weak and thready pulse, difficult to palpate
2+ Normal pulse, able to palpate with normal pressure
3+ Bounding pulse, may be able to see pulsation
This cranial nerve is tested using the Snellen chart.
What is Cranial Nerve II (Optic)?
Identify one culturally sensitive consideration during a musculoskeletal assessment.
What is asking permission before touching or assessing certain areas?
What is the purpose of the cover/uncover eye test?
What is to detect strabismus or ocular misalignment?
During suctioning, limit each suction attempt to this number of seconds.
What is 15 seconds?
Oxygen is considered a drug and must always be administered with this.
What is a provider order?
Name a developmental or cultural consideration when performing a thorax and lung assessment.
What is allowing for modesty concerns in some cultures or using age-appropriate communication?
No pulse is detected on palpation, even with firm pressure and doppler.
What is absent pulse - 0?
What are unexpected findings in a neurological assessment?
What are unequal pupils, slurred speech, or decreased grip strength?
What assessment tool is used to check for neurovascular status in a limb?
What is CMST? Color/circulation, movement, sensation, temp
Describe how to conduct the Whisper test and what it evaluates.
What is standing 2-3 ft behind the patient and whispering multiple words/numbers while they occlude opposite ear, patient repeats to assess auditory acuity?
Suctioning should be performed using this technique to reduce infection risk.
What is sterile technique?
This high-precision device delivers a set FiO₂ and is ideal for COPD patients.
What is a Venturi mask?
Describe the correct steps for collecting an expectorated sputum specimen.
What are instructing the patient to rinse their mouth, take deep breaths, cough deeply, and expectorate into a sterile container? (First thing in the morning.)
2mm indentation, rebounds immediately
What is Grade 1 pitting edema
Describe the procedure and purpose of the Romberg test.
What is standing with feet together and eyes closed to assess balance and proprioception?
(When is it positive?)
How do you document normal versus abnormal musculoskeletal findings?
What is using concise language, approved abbreviations, standardized tools and noting asymmetry or limitations?
To straighten the ear canal in an adult, pull the pinna in this direction.
What is up and back?
You observe bubbling mucus at the trach site and hear gurgling respirations. Your next action is?
What is suction the airway?
To promote oxygenation and lung expansion, position the patient this way unless contraindicated.
What is high Fowler’s or semi-Fowler’s?
High-pitched, musical adventitious sound caused by narrowed airways.
What is a wheeze?
The radial pulse is strong and easily palpable with moderate pressure.
What is 2+?
Difficulty swallowing, often seen after a stroke.
What is dysphagia?
(How do we assess for this?)
Muscle strength rating - The patient moves the limb fully against gravity and can overcome full resistance.
What is 5/5?
On palpation, the lymph nodes are small (<1 cm), mobile, soft, and non-tender.
What are normal lymph node findings?
Two signs that indicate the need for suctioning.
What are restlessness and decreased SpO2 sat?
A patient with COPD is typically kept at this oxygen saturation target to avoid respiratory drive suppression.
What is 88–92%?
A pulse-ox reading of < 90 % generally indicates this clinical problem.
What is hypoxemia?
What are the signs and symptoms of a DVT?
What are unilateral leg swelling, pain, redness. Pain does not subside with rest.
Loss of full control of body movements, leading to a staggering gait.
What is ataxia?
Excessive thoracic curvature resulting in a “humpback” appearance.
What is kyphosis?
Pupils equal, round, reactive to light and accommodation.
What is normal/PERRLA?
Trach care includes cleaning this part of the skin to prevent breakdown.
What is the stoma site?
Name two clinical signs that a patient may need supplemental oxygen.
What are dyspnea, low O₂ sat, cyanosis, restlessness?
Normal adult anteroposterior-to-transverse chest ratio expressed numerically.
What is 1 : 2
Explain the significance of differentiating S1 and S2 heart sounds during a cardiovascular assessment.
What is to evaluate valve function and identify potential abnormalities like murmurs?
(What does the grade/intensity of a murmur tell you?)
Slurred or slowed speech due to impaired motor control of the tongue and lips.
What is dysarthria?
Muscle strength rating - The patient has full ROM and can overcome gravity but can only partially overcome resistance.
What is 4/5?
To palpate the thyroid, place fingers just below this cartilage while the patient performs this action.
What is the cricoid cartilage and swallowing?
You should wait this long between suctioning passes to allow the patient to recover.
What is 30 seconds to 1 minute?
Patients on oxygen must avoid using this common personal care item near their face.
What is petroleum-based products (e.g., Vaseline)?
The earliest behavioral sign of hypoxia you might notice in an adult.
What is restlessness or anxiety?
6mm indentation, 30 secs to rebound
What is grade 3 pitting edema?
Inability to understand spoken language, often due to damage in Wernicke’s area.
What is receptive aphasia?
Describe how to perform passive shoulder abduction for ROM measurement.
What is support elbow & wrist, move arm laterally to ear level (180°) while patient relaxes? Do not move past the point of resistance or cause pain
The cranial nerve that controls smell.
What is Cranial Nerve I (Olfactory)?
This is a serious complication of dislodging a newly placed tracheostomy.
What is loss of airway or tracheostomy decannulation?
A patient becomes restless and tachycardic. This may be an early sign of what complication?
What is hypoxia?