NR 302 Final Exam
Actual Dx - - correct answer Actual Diagnosis related to (R/T) ________(Related
Factors) as evidenced by (AEB) ________ (Defining Characteristics)
Risk - - correct answer Risk for __________as evidenced by _________ (Risk
Factors).
Readiness - - correct answer Readiness for __________as evidenced by
"_________" (Defining characteristics).
Asthma - - correct answer chronic hyper-reactive condition. Obstruction.
Wheezing. Dyspnea, increased RR, use of accessory muscles, anxiety, prolonged
expiration.
Palpation- decreased tactile fremitus
Percussion- resonance. Hyperresonance with chronic.
Auscultation- wheezing, decreased voice sounds. Severe; no breath sounds.
Atelectasis - - correct answer obstruction of airflow. Increased RR, dyspnea,
cyanosis, trachea shift to affected side in severe cases.
Palpation- lack of tactile fremitus. decreased lung expansion on affected side
Percussion- dullness over affected area
Auscultate- absent or diminished but normal breath sounds bilaterally.
Chronic Bronchitis - - correct answer inflammation of tracheobronchial tree.
Early morning, congested, chronic productive cough. White or clear sputum.
Wheezes or rhonchi. Dyspnea, tachypnea, use of accessory muscles.
Emphysema - - correct answer COPD. Obstruction of the alveoli. Tripod posture.
Use of accessory muscles. Cyanosis. Clubbing of fingers. Pursed lip breathing. SOB
on exertion.
Palpation- Absent or decreased tactile fremitus. Decreased chest expansion.
Percussion- Hyper-resonance.
Auscultate- diminished but normal breath sounds bilaterally, decreased vesicular
sounds, wheezing.
,NR 302 Final Exam
COPD - - correct answer >90 costal angle. Barrel chest AP=T. ↓ Tactile fremitus
palp. Tripod posture. Use of accessory muscles. Cyanosis. Clubbing of fingers.
Pursed lip breathing. SOB on exertion.
Lobular Pneumonia - - correct answer infection of the alveoli, Consolidation.
Tachypnea, congested, hacking, productive cough, chills, chest pain with
breathing. Mucosal edema. Sputum- rust.
Palpation- increased tactile fremitus. Decreased chest expansion on affected side.
Percussion- dullness over affected area.
Auscultation- Egophony changes e to a. Clear Whispered pectoriloguy &
bronchophony. Bronchial breath sounds and crackles.
Pleural effusion - - correct answer fluid in the pleural space. Dyspnea. Tracheal
shift to unaffected side.
Palpation- Absent or decreased tactile fremitus. decreased chest expansion side
affected.
Percussion- Dullness
Auscultation- unilateral lung sounds. Decreased/absent breath/voice sounds.
Pleural rub.
Pneumothorax - - correct answer air in pleural space, collapse of the lung.
Tachypnea, tracheal shift to unaffected side.
Palpation- Decreased Tactile fremitus. Unilateral decrease or delay in respiratory
expansion.
Percussion- Hyper-resonance
Auscultation- unilateral of normal lung sounds. Decreased/absent breath/voice
sounds.
Congestive heart failure - - correct answer Increased pressure in the pulmonary
veins causes interstitial edema around the alveoli and may cause edema of the
bronchial mucosa. Pulmonary congestion.
, NR 302 Final Exam
Increased respiratory rate, shortness of breath (especially on exertion),
orthopnea, peripheral edema, pallor. S3. Hypertrophy. Dry cough.
Palpation- Normal tactile fremitus. Skin cool and clammy.
Percussion- Resonance.
Auscultation-Normal breath sounds and voice sounds. Wheezes or crackles at the
bases of the lungs.
◦ Left-sided CHF - - correct answer lung symptoms. 1st Fatigue. Pink frothy
sputum. Pulmonary edema. Hypoxia. SOB, crackles/rales, cough, orthopnea,
anxiety, confusion, PND. S3
Rt CHF - - correct answer peripheral symptoms. Skin pale, gray, or cyanotic;
nausea, vomiting; pitting edema, peripheral/bilateral edema, ascites, JVD, HJR,
weak pulse, cool moist skin, decreased urine output, increased B.P., weight gain,
liver congestion. Cor Pulmonale
Crackles/Rales - - correct answer discontinuous, intermittent, non-musical, and
brief. C-collapsed or fluid-filled alveoli open. end inspiration, do not clear w
cough.
Fine rales - - correct answer soft, high pitched, and very brief.
Coarse rales/crackles - - correct answer louder, moist, lower in pitch, longer,
bubbling.
Wheezes (sibilant) - - correct answer inspiration/expiration when severe.
continuous high pitched with a shrill quality. C- blocked air flow; asthma,
infection, foreign body obstruction.
Rhonchi (sonorous) - - correct answer Expiration/ inspiration. Change/disappear
w cough. Continuous low pitched with a snoring, rattling. Fluid-blocked airways.
Stridor - - correct answer inspiration. Loud high pitched crowing heard without
stethoscope. Obstructed upper airways.
Friction rub - - correct answer inhalation/exhalation. Low pitched grating,
rubbing, pleural inflammation
