CCRI Nursing 1010 Exam 4-
Fluid/Electrolyte/Physical
Assessment/Nutrition/Oxygenation &
Perfusion Questions and Answers.
Techniques of Assessment - Answer 1. inspection
2. palpation
3. percussion
4. auscultation
Techniques of Assessment (belly) - Answer 1. inspect
2. auscultate
3. percuss
4. palpate
Skin check ABCD - Answer Asymmetry
Border Irregularity
Color
Diameter
erythema - Answer redness of the skin
Where should turgor be assessed? - Answer sternum and forearm (sternum/forehead in
elderly)
clubbing of nails - Answer finding in the nails that indicates chronic hypoxia
capillary refill time - Answer should be less than 3 seconds
What does 20/20 vision mean? - Answer What a person with perfect vision can see at 20
feet, you can also see at 20 feet
what does 20/200 mean? - Answer that at 20 feet the patient can read print that a person of
normal vision can read at 200 feet. the larger the second number the worse the vision
,optic chiasm - Answer the point at which the optic nerves from the inside half of each eye
cross over and then project to the opposite half of the brain
What does PERRLA stand for? - Answer Pupils Equal, Round, Reactive to Light and
Acommodation
Average pupil size? - Answer 3-5 mm
how to inspect adult ear canal? - Answer pull pina up and back
how to inspect ear canal of child? - Answer pull pina back and down
What does the rhinne test for? - Answer bone conduction (against tmj) air conduction
(sideways)
Weber test - Answer hearing test using a tuning fork; distinguishes between conductive and
sensorineural hearing loss (on top of head)
What is a bruit? - Answer A bruit is a vascular sound that reflects partial arterial occlusion
vesicular breath sounds - Answer I>E
soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue
Bronchial lung sounds - Answer I=E
heard over trachea; expiratory sound predominates; is higher pitched and louder; if heard in
other locations it indicates consolidation -- a space that usually contains air now has fluid
bronchovesicular breath sounds - Answer I<E
Breath sounds normally heard in the posterior chest between the scapulae and in the center
part of the anterior chest in the adult; softer than bronchial sounds; about equal during
inspiration and expiration
Cardiac Auscultation - Answer stethoscope should be placed over the mitral valve area, in
the left fifth intercostal space over the apex of the heart to hear the first heart sound ("lub").
S2 sound (dub) - Answer Normal closure of aortic/pulmonary valves (end of systole)
,S1 sound (lub) - Answer normal closure of mitral and tricuspid valves, beginning of systole
Lung landmarks - Answer -Apex : highest point of lung tissue. 3-4 cm above the inner third of
clavicles
-Base: lowest border of lung tissue. Rests on diaphragm. Anterior location at 6th rib in
midclavicular line. Laterally at 7th or 8th rib. Posterior location at T 10.
adventitious breath sounds - Answer Abnormal breath sounds such as wheezing, stridor,
rhonchi, and crackles.
cardiac landmarks - Answer
Cardiac PMI refers to? - Answer point of maximal intensity
peripheral pulse sites - Answer -radial
-carotid
-brachial
-posterior tibialis
-dorsalis pedis pulses
*can be felt at peripheral (outlying) points of the body
pulse quality - Answer the rhythm (regular or irregular) and force (strong or weak) of the
pulse
How to rate pulse - Answer 0. absent, not palpable
1. pulse diminished, barely palpable
2. expected, normal
3. full pulse, increased
4. bounding pulse
peripheral edema - Answer Swelling in the limbs, particularly the feet and ankles, due to an
accumulation of interstitial fluid.
gynecomastia - Answer Abnormal development of breast tissue in males
Pitting Edema Scale - Answer 1+ A barely perceptible pit, 2mm
, 2+ A deeper pit, rebounds in a few seconds, 4mm
3+ A deep pit, rebounds in 10-20 seconds, 6mm
4+ A deeper pit, rebounds in >30 seconds, 8mm
abdomen quadrants - Answer -right upper quadrant
-left upper quadrant
-right lower quadrant
-left lower quadrant
liver is in the _____ quadrant - Answer upper right
stomach is in the _______ quadrant - Answer upper left
bowel sounds - Answer Abdominal sounds caused by the products of digestion as they move
through the lower gastrointestinal tract, usually heard on auscultation.
Borborygmi - Answer a rumbling or gurgling noise made by the movement of fluid and gas in
the intestines
Range of joint motion - Answer Used to determine limitation/ injury to a joint
Abduction - Answer Movement away from the midline of the body
Adduction - Answer Movement toward the midline of the body
Hypertonicity - Answer increased muscle tone
Goniometer - Answer instrument used to measure joint angles
Hypotonicity - Answer decrease in muscle tone
atrophy - Answer (n.) the wasting away of a body organ or tissue; any progressive decline or
failure
LOC test - Answer person, place, time
Fluid/Electrolyte/Physical
Assessment/Nutrition/Oxygenation &
Perfusion Questions and Answers.
Techniques of Assessment - Answer 1. inspection
2. palpation
3. percussion
4. auscultation
Techniques of Assessment (belly) - Answer 1. inspect
2. auscultate
3. percuss
4. palpate
Skin check ABCD - Answer Asymmetry
Border Irregularity
Color
Diameter
erythema - Answer redness of the skin
Where should turgor be assessed? - Answer sternum and forearm (sternum/forehead in
elderly)
clubbing of nails - Answer finding in the nails that indicates chronic hypoxia
capillary refill time - Answer should be less than 3 seconds
What does 20/20 vision mean? - Answer What a person with perfect vision can see at 20
feet, you can also see at 20 feet
what does 20/200 mean? - Answer that at 20 feet the patient can read print that a person of
normal vision can read at 200 feet. the larger the second number the worse the vision
,optic chiasm - Answer the point at which the optic nerves from the inside half of each eye
cross over and then project to the opposite half of the brain
What does PERRLA stand for? - Answer Pupils Equal, Round, Reactive to Light and
Acommodation
Average pupil size? - Answer 3-5 mm
how to inspect adult ear canal? - Answer pull pina up and back
how to inspect ear canal of child? - Answer pull pina back and down
What does the rhinne test for? - Answer bone conduction (against tmj) air conduction
(sideways)
Weber test - Answer hearing test using a tuning fork; distinguishes between conductive and
sensorineural hearing loss (on top of head)
What is a bruit? - Answer A bruit is a vascular sound that reflects partial arterial occlusion
vesicular breath sounds - Answer I>E
soft, fine, breezy, low-pitched sounds heard over peripheral lung tissue
Bronchial lung sounds - Answer I=E
heard over trachea; expiratory sound predominates; is higher pitched and louder; if heard in
other locations it indicates consolidation -- a space that usually contains air now has fluid
bronchovesicular breath sounds - Answer I<E
Breath sounds normally heard in the posterior chest between the scapulae and in the center
part of the anterior chest in the adult; softer than bronchial sounds; about equal during
inspiration and expiration
Cardiac Auscultation - Answer stethoscope should be placed over the mitral valve area, in
the left fifth intercostal space over the apex of the heart to hear the first heart sound ("lub").
S2 sound (dub) - Answer Normal closure of aortic/pulmonary valves (end of systole)
,S1 sound (lub) - Answer normal closure of mitral and tricuspid valves, beginning of systole
Lung landmarks - Answer -Apex : highest point of lung tissue. 3-4 cm above the inner third of
clavicles
-Base: lowest border of lung tissue. Rests on diaphragm. Anterior location at 6th rib in
midclavicular line. Laterally at 7th or 8th rib. Posterior location at T 10.
adventitious breath sounds - Answer Abnormal breath sounds such as wheezing, stridor,
rhonchi, and crackles.
cardiac landmarks - Answer
Cardiac PMI refers to? - Answer point of maximal intensity
peripheral pulse sites - Answer -radial
-carotid
-brachial
-posterior tibialis
-dorsalis pedis pulses
*can be felt at peripheral (outlying) points of the body
pulse quality - Answer the rhythm (regular or irregular) and force (strong or weak) of the
pulse
How to rate pulse - Answer 0. absent, not palpable
1. pulse diminished, barely palpable
2. expected, normal
3. full pulse, increased
4. bounding pulse
peripheral edema - Answer Swelling in the limbs, particularly the feet and ankles, due to an
accumulation of interstitial fluid.
gynecomastia - Answer Abnormal development of breast tissue in males
Pitting Edema Scale - Answer 1+ A barely perceptible pit, 2mm
, 2+ A deeper pit, rebounds in a few seconds, 4mm
3+ A deep pit, rebounds in 10-20 seconds, 6mm
4+ A deeper pit, rebounds in >30 seconds, 8mm
abdomen quadrants - Answer -right upper quadrant
-left upper quadrant
-right lower quadrant
-left lower quadrant
liver is in the _____ quadrant - Answer upper right
stomach is in the _______ quadrant - Answer upper left
bowel sounds - Answer Abdominal sounds caused by the products of digestion as they move
through the lower gastrointestinal tract, usually heard on auscultation.
Borborygmi - Answer a rumbling or gurgling noise made by the movement of fluid and gas in
the intestines
Range of joint motion - Answer Used to determine limitation/ injury to a joint
Abduction - Answer Movement away from the midline of the body
Adduction - Answer Movement toward the midline of the body
Hypertonicity - Answer increased muscle tone
Goniometer - Answer instrument used to measure joint angles
Hypotonicity - Answer decrease in muscle tone
atrophy - Answer (n.) the wasting away of a body organ or tissue; any progressive decline or
failure
LOC test - Answer person, place, time
