Physical Assessment
Cardiac Rhythms
Focused scenarios
Rapid Fire
Vocabulary
100
What are the four techniques used in physical assessment?
Inspection, Palpation, Percussion, Auscultation
100
Identify this rhythm
Normal sinus rhythm
100
A patient has crackles in the bases of the lungs. What condition might this indicate?
Fluid overload, pneumonia, or heart failure
100
What is the normal range for an adult respiratory rate?
12-20 breathes per minute
100
Abnormal condition in which the heart contracts regularly but at a rate greater than 100 bpm
Tachycardia
200
What breath sounds are normally heard over most of the lung fields?
Vesicular breath sounds
200
What is the hallmark rhythm characteristic of atrial fibrillation?
Irregularly irregular rhythm, no discernible P waves
200
Your patient has edema in both legs. Which finding would confirm it's related to heart failure?
Jugular vein distention, crackles in lungs, weight gain, decreased cardiac output signs
200
A patient's oxygen saturation is 85%. What is your immediate nursing action?
Apply oxygen, assess airway and breathing
200
This number represents the ventricles contacting, forcing blood into the aorta and the pulmonary arteries
Systolic pressure
300
Name two priority assessments for a patient admitted with shortness of breath.
Airway patency, oxygen saturation, lung sounds, respiratory effort
300
Identify this rhythm
Ventricular tachycardia
300
A patient becomes diaphoretic with chest pain radiating to the arm. What should your next action be?
Obtain vital signs, place on monitor, administer oxygen, notify provider (possible MI)
300
Identify this rhythm. What is the first action?
Rhythm: Asystole. First action: Begin CPR, check another lead to confirm
300
Yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver
Jaundice
400
A patient reports chest pain. List three focused cardiovascular assessments you would perform
Heart sounds, peripheral pulses, blood pressure, skin color, temperature, pain assessment
400
Your patient is unresponsive, pulseless, and this rhythm appears. What is your immediate action?
Begin CPR and prepare for defibrillation
400
You auscultate an S3 heart sound in an adult. What does this suggest?
Heart failure or volume overload
400
What is the normal rate of bowel sounds per minute
4 to 32
400
Red discoloration of the skin, such as with a rash or mild sunburn
Erythema
500
A nurse is assessing postoperative circulation of the lower extremities for a patient who had knee surgery. The nurse should include which assessments?
Skin color, edema, skin temperature, peripheral pulses
500
What is the rhythm, rate, and if it is regular or irregular?
Rhythm normal sinus rhythm, rate 80, regular
500
The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What breath sound is being heard?
Sonorous wheezes
500
Patient reports he coughed up blood during a particularly heavy coughing fit this morning. What wound the nurse document the presence of?
Hemoptysis
500
Bluish discoloration of the skin and mucous membranes.
Cyanosis