NR 302 Final Exam UPDATED 2022
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.
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.
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.
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.
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.
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.
