stridor- CORRECT ANSWERS ✔✔narrow, upper airway. High pitch, harsh,
inspiration
wheezes- CORRECT ANSWERS ✔✔narrow passage way. High pitch, continuous,
inspiration or expiration
crackles/rales- CORRECT ANSWERS ✔✔air moving through fluid. Fine: fluid in
alveoli; Course: fluid in larger airways.
Rhonchi- CORRECT ANSWERS ✔✔increased amt. fluid or secretions. Course
crackles, snoring noise
pleural friction rub- CORRECT ANSWERS ✔✔inflammation pleural lining
How do you notice a oxygenation problem?- CORRECT ANSWERS ✔✔Dyspnea,
restlessness, tachycardia, and tachypnea, decreased O2 sat, use of accessory muscles,
noisy breathing, flaring nostrils, change in skin color, position, change in loc
RN Interventions for Oxygenation- CORRECT ANSWERS ✔✔HOB Up, Adequate
fluid intake, humidification, comfortable surroundings, teach/encourage breathing
techniques, assist managing cough (suction), chest physiotherapy, provide oxygen,
give respiratory med
, s3 heart sound- CORRECT ANSWERS ✔✔abnormal older adult, too much blood
volume (heard best with bell)
s4 heart sound- CORRECT ANSWERS ✔✔blood not being able to get into heart
(heard best with bell)
Gallop- CORRECT ANSWERS ✔✔S3 and S4 (with S1 and S2)
Opening snap- CORRECT ANSWERS ✔✔diseased AV valve opening
Systolic click- CORRECT ANSWERS ✔✔diseased semilunar valve opening
Murmur- CORRECT ANSWERS ✔✔whooshing; turbulent flow in the heart (across
valve)
abnormal findings in perfusion- CORRECT ANSWERS ✔✔Variations in pulse
quality, pulse deficit, orthostatic hypotension, clogged arteries in body
Tachycardia- CORRECT ANSWERS ✔✔greater than 100 bpm
bradycardia- CORRECT ANSWERS ✔✔less than 60 bpm
hypotension- CORRECT ANSWERS ✔✔below 90/60
hypertension- CORRECT ANSWERS ✔✔above 120/80