NSG 3009/ NSG3009 Exam 3 (2026/2027 Update) Principles of Assessment | Questions & Answers | 100% Accurate Solutions | – South University

NSG 3009/ NSG3009 Exam 3 (2026/2027 Update) Principles of Assessment | Questions & Answers | 100% Accurate Solutions | – South University Q. What happens during systole? ANSWER Ventricles contract; blood pumped to body/lungs; AV valves close (S1); semilunar valves open. Q. What happens during diastole? ANSWER Ventricles relax and fill; AV valves open; semilunar valves close (S2). Q. What is the blood flow pathway through the heart? ANSWER Body → Vena cava → RA → Tricuspid → RV → Pulmonic valve → Pulmonary artery → Lungs → Pulmonary veins → LA → Mitral valve → LV → Aortic valve → Aorta. Q. What is the mnemonic for heart blood flow? ANSWER RA → RV → PA → Lungs → LA → LV → Aorta. Q. What is the SA node and its rate? ANSWER Primary pacemaker; 60-100 bpm. Q. What is the AV node and its rate? ANSWER Backup pacemaker; slows conduction; 40-60 bpm. Q. What is the rate of Purkinje fibers? ANSWER 20-40 bpm. Q. What happens if the SA node fails? ANSWER AV node takes over → bradycardia. Q. What does APE To Man stand for? ANSWER Aortic, Pulmonic, Erb's point, Tricuspid, Mitral. Q. Where is the aortic valve heard? ANSWER 2nd ICS right sternal border. Q. Where is the pulmonic valve heard? ANSWER 2nd ICS left sternal border. Q. Where is Erb's point? ANSWER 3rd ICS left sternal border. Q. Where is the tricuspid valve heard? ANSWER 4th ICS left sternal border. Q. Where is the mitral/apical pulse heard? ANSWER 5th ICS midclavicular line. Q. Where is the PMI located? ANSWER 5th ICS midclavicular line; displacement indicates LV hypertrophy or HF. Q. What is the cardiac output equation? ANSWER CO = HR × SV. Q. What increases cardiac output? ANSWER ↑ HR or ↑ SV. Q. What decreases cardiac output? ANSWER ↓ HR or ↓ SV. Q. What are symptoms of low cardiac output? ANSWER Cold skin, dizziness, hypotension, weak pulses. Q. What are expected pulse strengths? ANSWER 0 absent, 1+ weak, 2+ normal, 3+ strong, 4+ bounding. Q. What causes bounding pulses? ANSWER Fever, anxiety, fluid overload. Q. What causes weak/thready pulses? ANSWER Poor perfusion or shock. Q. What does fever do to HR? ANSWER Increases it (tachycardia). Q. What are symptoms of symptomatic bradycardia? ANSWER Dizziness, hypotension, syncope, SOB, confusion. Q. What are symptoms of tachycardia? ANSWER Palpitations, SOB, chest pain, dizziness, anxiety. Q. What causes S1? ANSWER Closure of mitral & tricuspid valves. Q. What causes S2? ANSWER Closure of aortic & pulmonic valves. Q. What causes murmurs? ANSWER Q. What should you assess with an irregular heart rate? ANSWER Apical pulse for 1 full minute. Q. What are the AV valves? ANSWER Tricuspid and Mitral valves. Q. What are the semilunar valves? ANSWER Aortic and Pulmonic valves. Q. What are symptoms of left-sided heart failure? ANSWER Dyspnea, crackles, pulmonary congestion. Q. What are symptoms of right-sided heart failure? ANSWER Edema, JVD, systemic congestion. Q. What are symptoms of an MI? ANSWER Crushing chest pain radiating to arm/jaw; SOB; diaphoresis; nausea. Q. What is the priority for suspected MI? ANSWER EKG + MONA (morphine, oxygen, nitro, aspirin). Q. What is a pericardial friction rub? ANSWER Scratchy/grating sound; relieved by sitting forward; indicates pericarditis. Q. What is normal urine output? ANSWER At least 30 mL/hr. Q. What counts as I&O? ANSWER Oral intake, IV fluids, tube feed, urine, emesis, wound drainage, measurable stool. Q. What is a normal respiratory rate? ANSWER 12-20/min. Q. What are expected respiratory findings? ANSWER Clear breath sounds; symmetrical rise; SpO₂ ≥ 95%; no accessory muscle use. Q. What causes bradypnea? ANSWER Opioid overdose, sedatives, increased ICP, metabolic alkalosis. What causes tachypnea? Fever, anxiety, pain, hypoxia, shock, acidosis. What causes crackles? Fluid in alveoli; HF or pneumonia. What causes rhonchi? Mucus in airways; clears with coughing. What causes wheezes? Narrowed airways; asthma or COPD. What is stridor? High-pitched obstruction sound; emergency. What is Cheyne-Stokes breathing? Cycles of deep → shallow → apnea; end-of-life or neuro injury. What are Kussmaul respirations? Deep, rapid breathing; DKA or metabolic acidosis. What is pleural effusion? Fluid in pleural space; decreased breath sounds; dyspnea. What is atelectasis? Collapsed alveoli; post-op; crackles; hypoxia. What are COPD findings? Barrel chest, wheezing, pursed-lip breathing, CO₂ retention. What are pneumonia symptoms? Fever, crackles, productive cough, consolidation on x-ray. What are PE symptoms? Sudden SOB, chest pain, tachycardia, anxiety, hemoptysis possible. What is orthopnea? Difficulty breathing when lying flat; HF or COPD. Cranial Nerve I Smell. Cranial Nerve II Vision. Cranial Nerve III Eye movement; pupil constriction. Cranial Nerve IV Down and inward eye movement. Cranial Nerve V Facial sensation; chewing. Cranial Nerve VI Lateral eye movement. Cranial Nerve VII Facial movement; taste. Cranial Nerve VIII Hearing and balance. Cranial Nerve IX Swallowing; taste. Cranial Nerve X Vagus nerve: HR and GI control. Cranial Nerve XI Shoulder shrug. Cranial Nerve XII Tongue movement. What are primary skin lesions? Macule, papule, vesicle, pustule. What are secondary skin lesions? Crust, ulcer, fissure. What do you assess in skin exams? Color, integrity, moisture, temperature, turgor, edema. What can an RN do? Assessment, teaching, unstable pts, new admissions. What can an LPN do? Stable pts, PO meds, wound care, reinforce teaching. What can a UAP do? ADLs, vitals (stable), hygiene, positioning. What is autonomy? Patient's right to choose. What is beneficence? Do good. What is nonmaleficence? Do no harm. What is justice? Fairness. What is veracity? Truth telling. What is fidelity? Keeping promises. What are signs of abuse? Bruises in stages, fearfulness, poor hygiene, inconsistent story; mandatory reporting applies. During systole, why do the AV valves close? To prevent backflow of blood into the atria when the ventricles contract. Why is diastole essential for cardiac output? It allows ventricular filling, which determines preload and stroke volume. How does increased afterload affect cardiac workload? It increases the force the heart must overcome, reducing stroke volume and cardiac output. What does narrowing of the aortic valve do to the heart? It causes left ventricular hypertrophy from increased resistance. Why does blood return to the right atrium through the vena cava? It carries deoxygenated blood from systemic circulation to restart the cycle. Why is the left ventricle the most muscular chamber? It must generate high pressure to pump blood into systemic circulation. What happens if the pulmonic valve fails to close properly? Blood regurgitates into the right ventricle, reducing oxygenation and cardiac efficiency. Why does SA node failure cause bradycardia? Backup pacemakers (AV node or Purkinje fibers) fire at slower intrinsic rates. Why is the AV node delay crucial? It ensures ventricles fill completely before they contract. What arrhythmia is likely if the AV node stops working? Third-degree heart block with severe bradycardia. Why do you assess Erb's point? It is best for hearing S1/S2 equally and detecting murmurs. What does a displaced PMI indicate? Possible left ventricular hypertrophy or heart failure. Why does tachycardia reduce cardiac output? The heart beats too fast to allow full ventricular filling. If stroke volume decreases, how does the body compensate? HR increases to maintain cardiac output. Why are bounding pulses seen in fluid overload? Increased circulating volume increases stroke volume and vessel pressure. Why are weak pulses seen in shock? Low circulating volume and poor perfusion reduce pulse strength. Why is S1 louder at the apex? AV valves are located near the apex, where S1 is heard best. Why is S2 louder at the base? Semilunar valves are located at the upper portion of the heart. Why do murmurs occur during valve stenosis? Blood must forcefully pass through a narrowed valve, creating turbulence. What is the priority assessment when a patient has an irregular heart rate? Check apical pulse for 1 full minute to assess rhythm accuracy. Why does left-sided HF cause pulmonary crackles? Blood backs into the lungs, causing fluid accumulation in alveoli. Why does right-sided HF cause edema? Systemic venous congestion causes fluid to collect in tissues. Why is nitroglycerin given during MI? It dilates coronary arteries, improving blood flow to heart muscle. Why is aspirin given during MI? It prevents further platelet aggregation and clot formation. Why does pericarditis pain improve when leaning forward? This reduces pressure on the inflamed pericardial sac. Why is urine output important in cardiac patients? It indicates kidney perfusion and therefore cardiac output. Why do opioids cause respiratory depression? They reduce brainstem activity controlling breathing. Why does hypoxia cause tachypnea? The body increases RR to improve oxygenation. Why are crackles heard in pneumonia? Fluid and exudate fill alveoli, impairing gas exchange. Why does rhonchi clear with coughing? It is caused by mucus moving in large airways. Why are wheezes common in asthma? Bronchoconstriction narrows airways, causing musical airflow sounds. Why is stridor a medical emergency? It indicates upper airway obstruction that may rapidly progress to respiratory arrest. Why do patients with DKA have Kussmaul respirations? The body tries to blow off excess CO₂ to correct acidosis. Why does atelectasis occur post-op? Shallow breathing and immobility collapse alveoli. Why does COPD cause a barrel chest? Chronic air trapping enlarges the thoracic cavity. Why does pneumonia cause consolidation on X-ray? Alveoli fill with fluid, pus, or pathogens. Why is a pulmonary embolism life-threatening? It blocks pulmonary blood flow, impairing oxygenation and causing strain on the right heart. Why does orthopnea occur in HF? Fluid redistributes when lying flat, worsening pulmonary congestion. Why is facial droop a concern in cranial nerve assessment? It may indicate stroke involving CN VII. Why must skin turgor be checked in dehydration? Poor turgor indicates fluid volume deficit. Why can't UAPs perform assessment? Assessment requires clinical judgment reserved for licensed staff. Why can't LPNs teach new material? Initial education requires RN-level critical thinking and legal responsibility. Why is autonomy important in patient care? It protects the patient's right to make informed decisions. Why is beneficence required in nursing practice? It ensures actions are made with the patient's best interest in mind. Why is mandatory reporting necessary for abuse cases? It protects vulnerable populations and is legally required. signs objective findings that can be seen, felt, heard, or measured symptoms subjective findings perceived by the patient homeostasis constancy in the internal environment of the body the four vital signs temperature, pulse, respiration, blood pressure 98.6 F or 37 C Normal mean body temperature oral, axillary, tympanic, rectal, temporal artery five common places to measure temperature 98.6 F O mean oral temperature 97.6 F Ax mean axillary temperature 97.6 F T mean tympanic temperature 99.6 F R mean rectal temperature 100 F TA mean temporal artery temperature rectal The most accurate method for taking a temperature is shivering respond to low temperature by sweat respond to high temperature by diaphoresis profuse sweating body temperature measurement of the degree of heat of the deep tissues of the human body hypothermia low body temperature hyperthermia Abnormally high body temperature, especially that induced for therapeutic purposes febrile pertaining to or characterized by fever 1 to 2 degrees normal degree variation for temperature respiration action of inhaling oxygen and exhaling carbon dioxide during breathing single respiration one inhalation and one exhalation inspiration breathing in expiration breathing out inspiration diaphragm contracts (down) expiration diaphragm expands (in) 12-20 breaths per minute normal respiratory rate for adult 20-30 breaths per minute normal respiratory rate for children (10 years old) 30-60 breaths per minute normal respiratory rate for newborn (1 year old) depth & pattern respirations measured by deep or shallow depth of breaths regular or irregular pattern of breaths tachypnea abnormal rapidity of breathing bradypnea abnormal slowness of breathing dyspnea difficult or labored breathing apnea cessation of spontaneous ventilation 21% percentage of oxygen in atmosphere O2 saturation how much oxygen is in the blood pulse oximeter O2 sats are measured with 95%- 100% normal O2 sats drug pure oxygen is a L/ min pure oxygen ordered in hypoxia reduction of oxygen supply to the tissue hypoxemia 90% in the blood; decreased oxygen tension (concentration) in the blood nasal cannula most commonly used oxygen delivery device nasal cannula delivers oxygen through short prongs inserted into the nares 1-4 L/min (never over 6 L/min) typical rate of nasal cannula simple O2 mask least commonly used oxygen delivery device simple O2 mask low-flow devices, cover the patient's nose & mouth greater than 6 L/min typical rate of simple O2 mask nonrebreathing mask has reservoir bag which allows for higher concentration of oxygen; mask has one-way valve to allow CO2 out 15 L/min typical rate of nonrebreathing mask aerosol mask prevent drying out of nasal passage; generate an aerosol mist with precise oxygen concentrations air-entrainment mask allows room air inside mask while breathing in O2; provides an accurate concentration of oxygen to the patient by propelling a high-velocity of source oxygen through a narrowed opening green label oxygen devices recognized by oxygen tent a canopy that surrounds the patient providing oxygen at a higher O2 concentration ventilator device used for patients who cannot breathe on their own; watch chest or machine radial, brachial, carotid artery three most common sites to measure pulse radial artery most common site to measure pulse left arm with second and third finger find pulse in beats per minute units to measure pulse 60-100 bpm normal pulse rate in adult 70- 120 bpm normal pulse rate for children (10 year old)p Electrocardiogram (ECG) measure pulse by series of electrodes placed over the patient's chest to record electrical activity of the heart and convert it to wave form arterial line catheter that has a transducer to measure pulse rate (swan-ganz) pulse oximeter probe placed on the finger that measures the intensity of light needed to penetrate the circulating blood tachycardia pulse rate is 20 bpm over normal resting pulse rate OR over 100 bpm bradycardia pulse rate falls below normal resting pulse rate blood pressure measure of the force of blood on the arterial walls during contraction & relaxation of the heart systolic peak pressure during the contraction phase diastolic pressure during the relaxation phase manual BP sphygmomanometer & stethoscope mm/Hg blood pressure recorded in 120/80 normal blood pressure 95-140/ 60-90 normal range of blood pressure hypertension multiple readings over 140/90 hypotension multiple readings less than 95/60 prehypertension 120-139/80-89 stage 1 hypertension 140-149/ 90-99 stage 2 hypertension 160/100 Endotracheal tube (ET tube) placed into the trachea to help with breathing intubation insertion of a tubular device into a canal, hollow organ, or cavity 1-2 inches above carina tip of ET tube atelectasis collapsed lung; absence of gas from part or the whole lungs as a result of failure of expansion or reabsorption of gas from the alveoli central (venous) line catheters inserted into a large vein; used to administer a variety of drugs subclavian vein central lines usually placed in 2-3 cm above right atrium central line placement PICC line (peripherally inserted central catheter) an indwelling line in patients who have difficult venous access or require frequent medication infusion peripherally inserted central catheter (PICC) PICC line 2-3 cm above right atrium PICC line placement infusaport used for long term IV access, inserted into subclavian vein pleural effusion increased amounts of fluid within the pleural cavity, usually the result of inflammation pneumothorax presence of air or gas in the pleural cavity chest tube (thoracostomy tube) tube placed into pleural cavity to alleviate pneumothorax & pleural effusion thoracentesis surgical puncture to remove fluid from the pleural space paracentesis surgical puncture of a body cavity for fluid removal pacemaker used for patients with bradyarrythmia & disease of electrical current of the heart implantable cardioverter defibrillator (ICD) electrical device implanted in chest cavity with electrodes to heart; applies shock to heart to stop potentially life-threatening arrhythmias such as fibrillation external pacemaker electrodes deliver stimulus through chest wall of intravenous catheter fracture to break (a bone) proximal and distal to site must lift fractures